Summer Intern Program

Would you like new students to contact you directly? Fill out this form and you will be included in the agency database for students to search for agencies around their home town.

To print a copy of this form to be faxed in, click here.

Fields with an asterisk (*) are required. You must be a PIIAI member to participate in the program.

Contact Name: *

Agency: *

Address: *

City: *

State: *

Zip: *

E-Mail: *

Phone: *

Fax:

Website:

Areas covered by your agency (Please check all that apply ):

Personal Lines
Commercial Lines
Life

Health
Long Term Care
Other (list below):

Goals of this position:

To print a copy of this form to be faxed in, click here.

Professional Independent Insurance Agents of Illinois
4360 Wabash Ave. • Springfield, Illinois 62711 • Ph: (800) 628-6436 • Fax: (217) 793-6744
Contact Shannon Churchill at (800) 628-6436, ext. 3004 or schurchill@piiai.org with questions.