Event Registration
 

Please complete all of the information in the sections requested.
There are three ways to submit this form to us:

Fill out the form below and click on the "Submit" button. Then send the correct fees to: Professional Insurance Agents of Kentucky, P.O. Box 4205, Frankfort, KY 40604.

Fax Complete the printable version and fax to 502-227-0839.

Regular Mail Complete the printable version and mail to: Professional Insurance Agents of Kentucky, P.O. Box 4205, Frankfort, KY 40604.

Please note: You are not considered fully registered until payment has been made. If you do not receive an invoice via e-mail within a couple of days after submitting , please call 502-875-3888.

Visa, MasterCard, & Discover accepted
 

Select Event
Event/Class

 Student Information

Student name  Name on Badge
Designations
Your e-mail address

First time to attend:
CIC Institute
CIC Institute in KY
CISR Seminar
Registration Type:
PIA Member
Nonmember
ADA Special Need
CE Credit Needed

Is this a CIC or CISR update?

Agency/Company Information

Firm Name
Street Address
Mailing Address
City, State, Zip

Office Phone (include A/C)
Home Phone (include A/C)
FAX (include A/C)

I have read and agree with the terms and conditions

Professional Insurance Agents of Kentucky
107 Consumer Lane
Frankfort Kentucky, 40601
Phone: 502-875-3888   *   Fax: 502-227-0839