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Urban Insurance Partners Institute
Membership and Contributor Form

The Urban Insurance Partners Institute is a nonprofit insurance industry organization dedicated solely to urban affairs.

The institute is funded entirely through the support of members and contributors. Members have an opportunity to serve on the Board of Directors, Advisory Board and committees, which determine UIPI policy and direction.

If you would like to support the work of UIPI and make a financial contribution, please complete the online form (encrypted for security purposes) or print the application below and mail or fax to:

Urban Insurance Partners Institute, 2835 N. Sheffield Avenue, Suite 213, Chicago, IL 60657  -  Fax (773) 880-8780.

For more information about becoming a UIPI member or contributor, contact the institute at (773) 880-8780.

Company Name
Chief Executive Officer
Street Address
City
State
Zip Code
Correspondence
Contact Name
Title
Street Address
(if different than above)
City
State
Zip Code
Telephone
Fax
Email
Support Level
Are you applying as a full member? Yes No
If so, do you wish to be nominated for the UIPI board of directors? Yes No
Are you applying as a contributor? Yes No
Company Background
Please tell us your most recent premium volume figures for the following:
Personal Lines Year
Commercial Lines Year
Do you use independent agents? Yes No
Do you use captive agents? Yes No
In which states are you licensed?
What are your primary lines of business?
What specific interests would you like the institute to address?
Would company representatives be interested in presenting our insurance education program through local community organizations?

Yes

No

Possibly, but we need more information.
Please send us any readily available public information on your company to help us better understand your urban affairs needs.
Newsletter
Should we send extra copies of the institute newsletter to you?
Yes Number of Copies No
If you want us to add company contacts to our mailing list please list them below

We appreciate your support and look forward to working with you!