Agency Membership Application
Thank you for your interest in membership with PIA Western Alliance!
Membership with the Western Alliance is organizational based. Meaning, once your agency joins, everyone that works at your agency location also becomes a member.
Please select the agency level (number of producers at your agency) and then scroll down to complete the online application. If you have multiple office locations, and would like those locations to also become a member, please also select the branch option for the reduced membership fee. (applicable if your main location joins at the appropriate agency price).
The top portion of the form (Individual Information) should include contact information for the primary contact person for the Agency. The Business Information portion of the form should include the general contact information for the agency (if different from the Individual Information).
If you wish to pay by check, please select "Invoice Me" at the bottom of the form.
Please confirm that your contact information is accurate (with correct spelling and punctuation) prior to submitting your application.
Once your application is received, we will send you additional paperwork to sign and return. We will also need a copy of your current Agency License and E&O Dec Page.
Please contact us at (888) 246-4466 if you have any questions!