Georgia Insurance Information Service, Inc.
PROSPECTIVE MEMBERSHIP INCENTIVE PROGRAM APPLICATION

Please print, complete and return this form to:
Georgia Insurance Information Service, Inc.
1225 Johnson Ferry Road, Suite 330
Marietta, GA 30068

If you have any questions please call David Colmans, 770-565-3806 or E-mail GIIS.

Applicant:

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Company or organization name

______________________________________
Title

Address:
______________________________________
______________________________________
______________________________________
______________________________________

Contact Person: _________________________
Voice: _________________________
Fax: _________________________
E-mail: _________________________

Incentive Program One-Year Fee: $___________

Program Participant fee is based on written premiums in Georgia for the most recent year.

Note: This incentive program is for one year from date of application. At the end of the period, the participant is encouraged to become a member in good standing of GIIS. If the anniversary of the incentive program participation date falls within the GIIS fiscal year's second, third or fourth quarter, the annual dues will be prorated accordingly until the Association's next fiscal year.

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Signature of Applicant
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Date