Step 1 of 5 20% I am...Please select your membership level below.*A Full-Time FarmerA Part-Time FarmerA Friend Of AgricultureA StudentAre you an insurance agent, or are you working with an insurance agent?*YesNoInsurance InformationGet ready to save! Please enter your insurance agent's information here.Agent Name*Agent Number*Agent Email* Agent Phone Number* Contact InfoMembership Number** First Name Middle Name Last Name Birthdate Date Format: MM slash DD slash YYYY Spouse's First NameSpouse's Last NameSpouse's Birthdate Date Format: MM slash DD slash YYYY Email* County*- Select -FairfieldLitchfieldNew HavenTollandHartfordMiddlesexNew LondonWindhamOut of StatePrimary Phone*Work PhoneCell PhoneAddress* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code Township(s) you are located in Farm InfoFarm NameSize of Farm Operation- Select -SmallMid-SizeLargeCommodities Produced Dairy Fruit Grains Hay Horses Livestock Poultry Vegetables Other Political PartyDemocratRepublicanIndependentSigned Up by (Member Number)Referred byComments or Requests Would you like to sign up for Auto-Renewal?*Yes! I'd like to save $5.00. Sign me up for automatic renewalNo. I do not want to sign up for automatic renewal Full Time Member 200 Price: $200.00 Full Time Member Auto 195 Price: $195.00 Part Time member 100 Price: $100.00 Part Time member Auto 95 Price: $95.00 Friend of Agriculture member 70 Price: $70.00 Friend of Agriculture member Auto 65 Price: $65.00 Student member 30 Price: $30.00 Your annual membership is only: $0.00 Payment Method*Credit CardeCheckCredit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Security Code Cardholder Name eCheck Name on Account Bank Name Routing Number Account Number CheckingSavingsAccount Type Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.
