Join Now

 
Please allow 24-48 hours for your application to be processed and approved. If you have any questions, please contact Jennifer Wickline, UStiA Member Services Coordinator.
   
Organization Information (to be displayed online)
Organization Name *
Address 1 *
Address 2
City *
State *
Zip *
Phone *
Fax
Website
Email *
Main Contact
First Name *
Last Name *
Address 1 *
Address 2
City *
State *
Zip *
Title
Phone *
Email *
Billing Address (if different)
Street
City
State
Zip
Mailing Address (if different)
Street
City
State
Zip
Additional Information
Referred by
How did you hear about us?
What is your reason for joining?
Please have someone contact me regarding
*Check all that apply
Business Resources
Community Involvement
Cost Savings Programs
(Insurance, Office Supplies, Worker's Compensation)
Economic Development
Government Relations
Networking
Other           
Membership Investment
Membership Type: *
Primary Directory Category *
Additional Directory Categories
**Hold CTRL on your keyboard to select multiple categories**
Additional Contacts

You are allowed up to 0 contact(s) for free. Each additional contact costs $250

   
Total: $ 

The contents of this box are for testing purposes. This box will be removed when the form goes live.
Full-Time Employees
Part-Time Employees
Hotel/Motel Rooms
Restaurant Seats
Additional Associates
Additional Associates Cost
Additional Locations
Additional Locations Cost
Assets
Assets Cost
AdditionalCategories
Additional Categories Cost
NumberOfAdditionalCategories
additionalItem1Cost
Annual Dues (charged to card)
Tax (charged to card)
Fee (charged to card)
tempValueForDropDown1
Revenue Item Number
Number of Full Time Employees:  
Number of Part Time Employees:  
Number of Rooms (Accommodations):  
Number of Seats (Restaurants):  
Number of Associates (Realtors, Attorneys):  
Number of Locations ($35/add. location):  
Millions in Assets (Financial Institutions):  
Enhanced Membership ($50):
$ 
$ 
$ 
*
NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.
Please click submit only one time.  The transaction may take several seconds.

US Travel Insurance Association