1.	Do you wish to receive a FREE subscription to American Agent & Broker?

Yes     No

First Name:
Last Name:
Job Title:
	(Ex: Director, Vice President, Project Manager, etc.)
Company Name:
	(Please provide your Company Name in full: abbreviations could disqualify you)
Address 1:
Address 2:
City:
State:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   American Samoa Guam Marshall Islands Micronesia (Federated States of) Palau Puerto Rico U.S. Minor Outlying Islands U.S. Virgin Islands Northern Mariana Islands Armed Forces Americas AA Armed Forces Middle East, Europe, Canada AE Armed Forces Pacific AP   Other
Zip:
Country:	UNITED STATES OTHER
	(Note: If your country is not listed above, subscriptions are not currently available at your location.)
Business Phone:
Fax:
Email:
	(Note: Valid email address is required or you could be disqualified.)

I do not wish to receive relevant third party offers and/or special promotions.

What is the approximate number of employees in your company? (select only one)

Select Number of Employees Less than 50 50-99 100-499 500-999 1,000-4,999 5,000-9,999 Greater than 10,000

Yes, please auto-fill my contact information for other publication qualification forms.

2.	Which professional designations do you hold? (select all that apply)

CPCU	AAI
CIC	Other (please specify)

3.	What is your primary business? (select only one)

Property/Casualty insurance agent or broker	Life/Health Insurance agent or broker
Property/Casualty managing gen. agent, surplus-lines broker, program mgr., MGU or other intermediary	Insurance Company Personnel
Property/Casualty Insurance Consultant	Other (please specify)

4.	How much property-casualty premium volume did your agency produce in the past year? (select only one)

$999,999 or less	$11 Million - $20.999 Million
$1 Million - $5.999 Million	$21 Million or more
$6 Million - $10.999 Million

5.	What percent of your agency's premium volume is from sales of commercial lines? (select only one)

0 - 25%	51 - 75%
26 - 50%	76 - 100%

6.	How many producers work in your agency? (select only one)

1 - 5	11 - 15
6 - 10	16 or more

7.	In lieu of a signature, we require a personal identifying question. What is the day of the month you were born?

Select day of month 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Would you like to receive EMAIL notices of other print or online publications, and other relevant offers from TradePub.com?

Yes     No

Would you like to receive relevant information from TradePub.com on behalf of third party businesses/organizations?

Yes     No

YOUR EMAIL IS CAPABLE OF SO MUCH MORE! Act now for your Free Trial - OnLetterhead turns your email from "white" to "wow". Plugs into your existing email program & includes links to your site, specials, & more. Custom email templates! 1,000's of customers. Inexpensive & effective! Email newsletters also available. Free trial today. Business use only. Note: Offer Valid in the United States Only.

Discover how to find new customers online. Spot Runner brings you new prospects with Online Advertising. We put your business on major search engines like Google, Yahoo, and create you a free video for sites like YouTube! Click to learn more about Spot Runner's Online Advertising solution today! Note: Offer Valid in the United States Only.

Request Your Free Research Report - Getting the Most for Every Dollar: Tools and Strategies for Expense Management at Mid-Size Companies, to see how other mid-sized companies are using corporate cards and other strategies to control expenses. For the sixth consecutive year, American Express has teamed up with CFO Research Services to identify how finance executives manage spending programs to yield sustained business results. This year's research, Getting the Most for Every Dollar, is a guide for CFOs interested in gaining insight on how other Middle Market companies can strike the appropriate balance in achieving price, service and quality to manage indirect expenses. Note: Offer Valid in the United States Only.