Certified Professional Insurance Agent (CPIA)
Registration Form
Blue
fields are
Required
YOUR INFORMATION
Name:
First Name
M.I.
Last Name
Suffix
Designations:
Agency/Company:
Address:
City:
State:
ZIP:
Phone:
Fax:
Cell Phone:
Email Address:
License Number:
Birth Date:
Month...
January
February
March
April
May
June
July
August
September
October
November
December
,
CLASS REGISTRATION
PIA Member ($170.00 per class)
Non-PIA Member ($190.00 per class)
This is my first CPIA class
This is my CPIA designation update
To register for a class, click the checkbox next to the Course Title and then select the Class Date and City
Course Title:
Class Date and City:
Disaster and Continuity Planning for Businesses and Families
Select class...
February 9, 2023 (Webinar)
CPIA 1
Select class...
March 9, 2023 (Webinar)
September 12, 2023 (Webinar)
CPIA 2
Select class...
April 11, 2023 (Webinar)
October 5, 2023 (Webinar)
CPIA 3
Select class...
May 23, 2023 (Webinar)
November 14, 2023 (Webinar)
The Registration Fee of $170.00 per class is available to PIA members
only
. This application is accepted contingent upon verification of the applicant's membership. The class rate will be increased to the non-member rate of $190.00 per class should the applicant be found not to be a PIA member.
NEW CANCELLATION POLICY FOR 2023
— Cancellations received within 3 days of the class will incur a $25.00 non-transferable fee. No-shows will forefit the entire registration fee.
PAYMENT INFORMATION
Registration Fee for Classes Selected Above:
$0.00
Payment Information:
Payment is due prior to the class — late payments will be assessed a $25 fee.
Method of Payment:
Visa
MasterCard
American Express
Check
A 3% Processing Fee Will Be Charged To All Credit Card Transactions.
Name (as it appears on the card):
Credit Card Number:
Code:*
Expiration Date:
Month...
January
February
March
April
May
June
July
August
September
October
November
December
Year...
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
Credit Card Billing Address:
City:
State:
ZIP Code:
* Your three-digit security code on the back of your card, or the four-digit Credit Card ID (CCID) on the
front of your card, if paying by American Express
By checking this box and submitting this form, you authorize and commit to the payment of
$0.00
for CPIA class registration, per the cancellation policy described above.