Georgia Insurance Information Service, Inc.
MEMBERSHIP 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:

______________________________________
Company or organization name
______________________________________
Title

Address:
______________________________________
______________________________________
______________________________________
______________________________________

Contact Person: _________________________
Voice: _________________________
Fax: _________________________
Email: _________________________

Membership Fee: $___________

GIIS Member Dues are based on written premiums in Georgia for the most recent year.

Note: Membership fee is for one year from date of application.

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Signature of Applicant
 ______________
Date