Have a question before you sign up?

Contact David Holton for any queries or information in relation to membership:

Tel: 01 492 2202
E-mail: david.holton@piba.ie

Become a PIBA Ireland Member

Step 1:	Fill out the below Application form and submit Alternatively, you can download a copy of the application form PDF and post it to PIBA, Unit 14B Cashel Business Centre, Cashel Road, Crumlin, Dublin 12.
Step 2:	Download here the Direct Debit form and post it to us PIBA, Unit 14B Cashel Business Centre, Cashel Road, Crumlin, Dublin 12.

Application Form - Professional Insurance Brokers Association

Your Name	*
Company Name	*
Trading Name	*
Company Address	*
Phone	*
Mobile
Fax
CB Number	*
Status Applied To select multiple options hold down the CTRL key and click on the options you wish to select	*
Directors Email	* (This address will be kept confidential and is only used for sending relevant information)
Other Emails	* (This email address will appear on our website along with your company details and it will received all information sent from PIBA)
Website
No of Sales Employees
No of Admin Employees

Activities

Life		No of agencies
Please list
General		No of agencies
Please list
Mortgage		No of agencies
Please list
Other
Describe briefly

Additional information Requests

Payment Option

Please tick your preferred payment option	Current Joining Fee €875 Monthly (€75 per month)

Terms & Conditions

*Mandatory fields are marked with an asterisk
Yearly Fee is €875, membership up to the 1st March 2012
Monthly Fee is €75 and will be taken on or just after the 1st of each month.Minimum subsription for Membership is up until renewal period March 2012.
Please enclose a cheque payable to PIBA for €875 or a direct debit mandate and return to PIBA, 14B Cashel Business Centre, Cashel Road, Crumlin, D 12

PIBA is the largest association in Ireland representing independent insurance and mortgage Brokers, with 900 member firms throughout the country. We represent:

Life Brokers
General Insurance Brokers
Mortgage Brokers