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TSLA Virtual University Home Page

Texas Insurance Unlimited CE Package

Contact Information:

Phone: 512.343.9058

Thank you for visiting TSLA, a non-profit, trade association of excess and surplus lines brokerage and underwriting professionals. If you would like more information about our association and membership benefits, please contact us at your convenience:

phone:
512.343.9058

fax:
512.343.2896

address:
Great Hills Corporate Center
9020-I Capital of TX Hwy N., Suite 370
Austin, TX 78759

email:
jptsla@tsla.org

information:
Info Request Form

TSLA Application for Associate Membership

Online Registration

To Complete This Application:

All questions must be answered completely.
All information contained in this application will be held in strict confidence.
Please remember to include a sponsorship letter from a TSLA Voting member.
Please include a $50 non-refundable application fee with your application. The association will bill you for the membership dues when application is accepted. Dues are prorated.
Annual dues for Associate Membership are $1000.
Failure to disclose material facts or misrepresentation contained in this application shall cause reason for automatic rejection or expulsion from TSLA.

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Please complete the sections below:

General Information
This section must be completed in order to apply online
Name of Firm:
Contact Name:
Indicate Whether Your Firm Is:

Information For Contact Person Listed Above:
Phone #:	(800)#:
Fax #:

Address:
City/State/Zip:	,

Email Address:
Web Site Address:

Provide complete address, phone and fax numbers(s) and contact name(s) of all branches in Texas below:

Detailed Information
This section must be completed in order to apply online
Indicate Whether Your Firm Is:
If "Other", please describe here:

Provide details and relationship of any other insurance related operations owned by or affiliated with applicant or principal owner:


Have you ever held any insurance license(s) under any other name?
Yes No If yes, please provide name(s):

During the past ten (10) years, have you or any business entity with which you were associated ever refused a professional, occupational or vocational license by any public or governmental licensing agency or regulatory authority?
Yes No If yes, please provide details:

Have you or any other member of your firm had a license refused, revoked or suspended?
Yes No If yes, please provide details:

Have you or any other business entity with which you have been associated been convicted and/or sentenced for any misdemeanor or felony involving theft, larceny, fraud, charging a violation of any corporate securities statute or any other insurance laws?
Yes No If yes, please provide details:

Submission Information
1) Please fax or mail a letter of sponsorship from a Voting TSLA member.

2) Name of President, Managing Partner or Owner:

3) Your Name and Title:

4) Date:

Payment Information
Please Note: *A $50 non-refundable* fee is required for this application submission.**
Amount Due:	$
Payment Method:	Invoice Me Check Credit Card

Additional Comments

Please enter any additional comments in regards to this online submission.

Please check the box below and then press the Submit button to send your application to TSLA. Please review your information for accuracy before submitting this form. TSLA is not responsible for any incorrect information entered into this form.

You must check the box below in order to submit your registration:

I agree to allow TSLA to bill my credit card (if applicable) and have reviewed all info I have provided for accuracy.

PLEASE NOTE: If you would rather fax or send your application via regular mail, please use the Print Application button below and then fax or mail to the number or address listed below.

and / or

If you would like to fax or mail your registration form, please fax or mail to:

Texas Surplus Lines Assn., Inc.
9020-I Capital of Texas Hwy N. #370
Austin, Texas 78759
Fax# (512) 343-2896

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