Registration Form

Please provide the following information. Create an Affiliate ID and Password using
alphanumeric characters only. You will need to enter your Affiliate ID and Password
to access the Affiliate Management Area at TravelInsuranceCenter.com.
* denotes a required field, if not applicable please enter N/A.
Your TravelInsuranceCenter.com Affiliate ID and Password
Affiliate ID:*
Password:*
(Between 6-20 alphanumeric characters)
Confirm Password:*
 
Contact Information
Business Name:*
Title:*
First Name:*
Last Name:*
Email Address:*
Website URL: (If applicable)
Street Address 1:*
Street Address 2:
City:*
State:*
Postal Code (zip):*
Province / Region / District:
(If non-US)

Country of Residence:*
Phone:*
Fax:
 
License Information (If applicable)
Insurance Licenses:
  Life/Health insurance       Surplus Line insurance       Property/Casualty insurance       Travel       Other  
IMG Agent Number:
(If currently licensed with International Medical Group)
 
Tax and Payment Information
Tax ID or Social Security # (US Only):
Make payment payable to:*
 
Contract Information
Review the Affiliate Marketing Agreement and select "I have read and accepted the above agreement" to continue. You can print out the agreement by viewing the agreement in .pdf format (Adobe Acrobat required)
I have read and accepted the above agreement
I disagree with the agreement
Agreement
Schedule
 
The Travel Insurance Experts