NABIP | Application

City: *

State: *

Zip Code: *

Cell Phone *

Work Phone *

What STATE chapter of NAHU do you belong? *

What LOCAL chapter (if any) of NAHU do you belong? *

Have you and if so, what positions do you hold within local, state or national levels of NAHU (include dates)? *

What awards (if any) have you won within local, state or national levels of NAHU? *

At what level do you contribute to HUPAC and for how many years? *

What areas of practice within the insurance industry do you specialize (i.e. Medicare, Small/Large group, fully insured/self-funding, life, disability, voluntary worksite, etc)? *

Name

Company

Full Address

Relationship

Phone

Name

Company

Full adddress

Relationship

Phone

Name

Company

Full Address

Relationship

Phone

Please comment on additional attributes you believe distinguish you from others that will qualify you to become a member of PAN.

I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in this application process may result in my disqualification to PAN and that information provided will be confirmed. I also understand that completing this application does not automatically qualify me for immediate membership into PAN. *