Program Administrator Membership Requirements for membership: Administration of one program with binding authority and minimum annual gross premium revenue of $1MM. All information will be treated as confidential. No specific details regarding your program will be released to anyone without your prior authorization. Membership Selection * Program Administrator - $ 1,000.00 Total Amount Applicant Information To ensure your application submits correctly, please avoid pasting any text with formatting (such as bold, italics, or special fonts). We recommend copying text only from plain text documents like Notepad, which removes any unwanted formatting. Program Administrator Name * Street Address * City * State * - select State/Province - Aberdeen City Aberdeenshire Aguascalientes Alabama Alaska Alberta American Samoa Angus Antrim and Newtownabbey Ards and North Down Argyll and Bute Arizona Arkansas Armagh City, Banbridge and Craigavon Armed Forces Americas Armed Forces Europe Armed Forces Pacific Baden-Württemberg Baja California Baja California Sur Baker Island Bayern Bedfordshire Belfast Berkshire Berlin Blaenau Gwent Brandenburg Bremen Bridgend Bristol, City of British Columbia Buckinghamshire Caerphilly California Cambridgeshire Campeche Cardiff Carlow Carmarthenshire Causeway Coast and Glens Cavan Ceredigion Cheshire Chiapas Chihuahua City of Hamilton Clackmannanshire Clare Clwyd Co Antrim Co Armagh Co Down Co Fermanagh Co Londonderry Co Tyrone Coahuila Colima Colorado Connecticut Conwy Cork Cornwall County Durham Cumbria Delaware Denbighshire Derbyshire Derry City and Strabane Devon Devonshire District of Columbia Distrito Federal Donegal Dorset Dublin Dumfries and Galloway Dundee City Durango Dyfed East Ayrshire East Dunbartonshire East Lothian East Renfrewshire East Riding of Yorkshire East Sussex Edinburgh, City of Essex Falkirk Fermanagh and Omagh Fife Flintshire Florida Galway Georgia Glasgow City Gloucestershire Greater Manchester Guam Guanajuato Guerrero Gwent Gwynedd HaDarom Haifa Hamburg HaMerkaz Hamilton Parish Hampshire Hawaii HaZafon Herefordshire Hertfordshire Hessen Hidalgo Highland Howland Island Idaho Illinois Indiana Inverclyde Iowa Isle of Anglesey Isle of Wight Jalisco Jarvis Island Jerusalem Johnston Atoll Kansas Kent Kentucky Kerry Kildare Kilkenny Kingman Reef Lancashire Laois Leicestershire Leitrim Limerick Lincolnshire Lisburn and Castlereagh London Longford Louisiana Louth Maine Manitoba Maryland Massachusetts Mayo Meath Mecklenburg-Vorpommern Merseyside Merthyr Tydfil Mexico Michigan Michoacin Mid and East Antrim Mid Glamorgan Mid Ulster Midlothian Midway Islands Minnesota Mississippi Missouri Monaghan Monmouthshire Montana Moray Morelos Na h-Eileanan Siar Navassa Island Nayarit Neath Port Talbot Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador Newport Newry, Mourne and Down Niedersachsen Nordrhein-Westfalen Norfolk North Ayrshire North Carolina North Dakota North Lanarkshire North Yorkshire Northamptonshire Northern Mariana Islands Northumberland Northwest Territories Nottinghamshire Nova Scotia Nuevo Leon Nunavut Oaxaca Offaly Ohio Oklahoma Oldham Omagh Ontario Oregon Orkney Islands Oxfordshire Paget Palmyra Atoll Pembroke Pembrokeshire Pennsylvania Perth and Kinross Powys Prince Edward Island Puebla Puerto Rico Quebec Queretaro Quintana Roo Renfrewshire Rheinland-Pfalz Rhode Island Rhondda, Cynon, Taff Roscommon Rutland Saarland Sachsen Sachsen-Anhalt Saint George's San Luis Potosi Sandys Saskatchewan Schleswig-Holstein Scottish Borders Shetland Islands Shropshire Sinaloa Sligo Smiths Somerset Sonora South Ayrshire South Carolina South Dakota South Glamorgan South Gloucestershire South Lanarkshire South Yorkshire Southampton Staffordshire Stirling Suffolk Surrey Swansea Tabasco Tamaulipas Tel-Aviv Tennessee Texas Thüringen Tipperary Tlaxcala Torfaen Town of St. George Tyne and Wear United States Minor Outlying Islands Utah Vale of Glamorgan, The Veracruz Vermont Virgin Islands Virginia Wake Island Warwick Warwickshire Washington Waterford West Dunbartonshire West Glamorgan West Lothian West Midlands West Sussex West Virginia West Yorkshire Westmeath Wexford Wicklow Wiltshire Wisconsin Worcestershire Wrexham Wyoming Yucatan Yukon Territory Zacatecas Zip * Website * Phone * Email * List all associations of which PA is a member Lloyd's coverholder Yes No Current Program Carrier Reference: Name * Current Program Carrier Reference: Company * Current Program Carrier Reference: Phone * Current Program Carrier Reference: Email * Include contact name, company, email, and phone. Target Markets Member/Industry-Related Individual with Contact Information Ownership Structure - select Ownership Structure - Privately Owned Private Equity Partnership Corporate Ownership Other Ownership Structure: Other Program Data Length of time in Program Business (in years) * Age of your oldest program (years) * Largest Program * Number of in force programs * Total premium in force * Which carriers underwrite your program? What are 3 positive attributes of your program that differentiate it from others in marketplace? List 3 enhancements/improvements to your current program that you would like implemented. % Program/MGA (binding authority) % Wholesale % Retail Program industries/classes of business * Accident and Health Accountants Actuarial Consultants Agency and Association Captives Agent insurance and real estate Agricultural Related Business Aircraft Airport Allied Health Amusement parks and rides Apartments Appraisers Architects and Engineers Armored Cars Artisan Contractors Asbestos & Lead Abatement Assisted Living Associations Attorneys Auctions and farmers markets Auto and truck dealers Auto Dealer Automobile Auto Physical Damage Auto Products Auto Services Aviation Bail/Immigration Bonds Bankers Banks and financial institutions Bars and Taverns Beauty Salons Behavioral Health Boat/Yachts Boat and recreation dealers including marinas Boiler/Equipment Breakdown Bond Programs BOP Breweries and wineries Brown water Hull Builders Risk Camps Canine Care Providers Cargo Casinos CAT Coverage Chemical and Petroleum Chiropractors Clubs golf Clubs other than golf Coastal Property Coastal Wind Commercial Automobile Community Associations Community Service Associations Condominiums and Apartments Construction Construction Wrap Up Consultants Contractors artisan Contractors Crane and rigging Contractors demolition Contractors electrical Contractors elevator Contractors energy Contractors environmental Contractors Equipment Contractors excavation Contractors general Contractors HVAC Contractors infrastructure Contractors janitorial Contractors residential construction Contractors solar Contractors sprinkler including alarm Contractors wrap up Correctional Cosmetics/Tattoo/Body Piercing Crane & Rigging Credit Guarantee Credit Insurance Crime Cultural Institutions Cyber Coverage Data Breach Dealers Open Lot Dentists Dry cleaning and laundry Earthquake Electrical Contractor Electronic Equipment Emergency Transport Energy Engineers Entertainment Centers Environmental EPLI Equine Equipment Floaters/Breakdown Events Extended Warranty Livestock operations Farming Operations Fidelity and Crime Fiduciary Liability Film Financial Institution Fine Arts Firearm sales including manufacturing Fire Sprinkler/Alarm Fitness Centers Food Services Forest Products Gaming Garage Dealer & Service General Contractors Golf Grocery Stores Habitational Hazardous Products Healthcare High Value Property Historic Sites Home Builders Home Health/Staffing Home Inspectors Hospitality Hotel/Motel Installation Insurance Agents Intellectual Property Jewelers Block Labor Professional Landscapers Laundry Law Practices Lease and Loan Services Logging Maintenance Services Management Liability Manufactured Housing Manufacturing Marinas Marine and Hull Liability Medical Devices/Facilities Medi Spas Mental Health Midwives Mining Misc E&O Mobile Home Park Mortgage Brokers Motorsports Motor Truck Cargo Moving and Storage Municipalities Musical Instruments Network Security Night Clubs/Adult Entertainment Non-Coastal Property Non Emergency Medical Transportation Non Profits Non Subscription Nuclear Energy Nurses Nursing Homes Parking Garage PEO Operations Personal Umbrella Pest Control Pet Pet Care Pharmaceutical Manufacturing Physicians Physicians/Surgeons Playground Equipment Installers/manufacturers Podiatrists Pollution Private Investigators/Security Professional Liability Property Property Management Psychiatrists Public Entity Public Transportation Pyrotechnics Railroad risks Real Estate Agents/Appraisers Religious Institutions Rental Business Repossession/Towing Residential Care Facilities Restaurants Restaurants all other Restaurants franchise Retail stores Roofing Schools Schools - Other Schools - Private Schools - Public Security Guards Self-Storage Senior Living Short Tail Business Social Services Solar Sporting Clubs Staffing Business Storage Tank Structural Engineers Taxi/Livery Technology & Media Temporary Staffing Terrorism Title Agents Tool/Instrument Towing and repossession Trade and Foreign Credit Trucking USL&H Utilities Utilities energy Utilities water and sewer Vacant Building Valet Warranty Weather Wildlife Wind Wineries Zoo contractor - plant ATM/Storage Unit Cannabis Strip Mining Weapons of Mass Destruction Aircraft Leasing Top Programs * Program Administrator History Please provide a brief explanation of the PA's carrier changes in the past 10 years. Has the PA ever had a carrier contract cancelled for cause? * Yes No Carrier contract cancelled explanation Are you and/or the PA a plaintiff in any current or soon to be filed suits? Yes No Plaintiff in any current or soon to be filed suit explanation Are you and/or the PA aware you may be a defendant in any pending litigation? * Yes No Defendant in pending litigation explanation Has the PA had an E&O claim in the past 5 years? * Yes No E&O claim explanation Have you or anyone employed at the PA ever had an insurance license refused or revoked? * Yes No Insurance license refused/revoked explanation Have any of the PA's associates who are licensed agents ever been subject to disciplinary proceedings leading to consent agreements with a regulator? * Yes No Disciplinary proceedings explanation If the PA collects and submits E&S taxes, has it ever had a delinquent or erroneous filing? * Yes No E&S delinquency explanation Involvement in Target Markets The Association strives to provide its members with significant benefits. Which aspects interest you the most? Networking with your peers Cross-sell opportunities Reviewing technological innovations with Program Business applications Meeting insurance companies committed to Program Business Meeting with service providers who support Program Business initiatives Learning new marketing techniques or exploring different distribution methodologies Exploring alternative risk transfer vehicles Participating in the Mid-Year and/or Summit meetings Exploring reinsurance options for your program Other What are the top 3 benefits you expect to derive from your first full year of membership? Attestation * Yes No By submitting this application: 1) The applicant attests that all information in the application is correct. 2) The applicant will abide by the Association Bylaws as they may be amended from time to time. 3) The applicant is not aware of any reason why the Bylaws cannot be observed. 4) The applicant agrees to comply with the TMPAA Code of Conduct. Account Please enter a Username to create an account. If you already have an account please login before completing this form. Username * Check Availability Punctuation is not allowed in a Username with the exception of periods, hyphens and underscores. Password Confirm Password Provide a password for the new account in both fields. Primary Contact First Name * Last Name * Phone * Email * Payment Options [x] Payment due upon approval. Review your contribution Additional Individuals Actively Participating in the Association First Name Last Name Email 1 2 3 4 5