Associate Membership Application – Florida Surplus Lines Association

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Membership
FSLA Convention
Legislative/SURPAC
- SURPAC
- Committees
Education
About FSLA
Surplus Lines 101

Associate Membership Application

Associate Membership Application

Company/Firm Name:*
Contact First Name:*
Contact Last Name:*
Professional Designations:
Contact Title:*
Address*
Principal Address: Address Line 2 City State / Province / Region ZIP / Postal Code
Mailing Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone:*
Toll Free:
Fax:
Email:*
Taxpayer ID #:
Website Address:
FEIN #:
BACKGROUND
Year Business was Established:
Please provide a brief description of the nature of your operations below:
Is the company engaged in, owned by, associated or affiliated with or controlled by any other business interest?
- Yes
- No
If yes, please give a brief explanation below:
Professional Associations to which you belong:
- Select All
- WSIA
- FAIA
- PIA
- Other
If Other, please list below.
Please list 3 Surplus Lines Agencies representing you in Florida:
Surplus Lines Agency Actions
Edit

Delete
There are no Agencies.
Maximum number of agencies reached.
How did you hear about us?
Why are you interested in joining?
How do you rate your experience with the surplus lines industry?
Comments
FSLA ANNUAL MEMBERSHIP
Associate Membership ($1,250)
- Associate Membership ($1,250)
SurPac Suggested Contribution
- Yes, I would like to contribute $1,000 to the SurPac!
- No, thank you.
Yes, I would like to contribute a unique amount to the SurPac!
Payment Information
Billing Address*
Street Address Address Line 2 City State ZIP Code
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Total
$0.00
Notice: Florida Surplus Lines Association dues are not deductible as a charitable contribution for federal tax purposes, but may be deductible as a business expense. The current tax code eliminates the portion of your dues attributable to lobbying expenses. It has been determined that 34% of your dues are used for these purposes, therefore only 66% of your dues are deductible as a business expense.
BY SUBMITTING THIS FORM, I HEREBY DECLARE THAT THE ANSWERS GIVEN WITH RESPECT TO THE FOREGOING QUESTIONS ARE TRUE, COMPLETE, AND ACCURATE WITH NO MISREPRESENTATION, OMISSIONS, OR ANY OTHER CONCEALMENT OF FACT.
Name of Applicant:
Title of Applicant:
Date of Application:
Date Format: MM slash DD slash YYYY
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Membership
FSLA Convention
Legislative/SURPAC
- SURPAC
- Committees
Education
About FSLA
Surplus Lines 101

Menu

Membership
FSLA Convention
Legislative/SURPAC
- SURPAC
- Committees
Education
About FSLA
Surplus Lines 101

Phone

850.224.0711
850.222.3019 (Fax)

Address

325 John Knox Rd. #L103,
Tallahassee, FL 32303

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