Joan Siering  
 Joan Siering Insurance
 Insurance Specialist
 Since 1983              

 415.648.8700  or  510.550.1604 
 510.601.5079 fax

www.jsins.com

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 Home | Customer Service | Affiliates   
   

 

Affiliate Registration

You can register yourself to be a user of our Affiliate Web by filling out and submitting this form. Only registered users are allowed into our Affiliate Web. Enter a Name with no spaces, which will be your username. Also create a private password. Together these will be your "key" into our Affiliate Web from now on. This information will be kept in a registration database that is accessible only to the webmaster, not to ordinary users.

SIGN UP HERE

First Name:    Last Name: 

Work phone:    ### ### ####

Cell phone:    ### ### ####

Fax:   ### ### ####

E-Mail Address:  name@jsins.com

Who Referred You?

Enter your User Name
  -- this will be your username

Please choose a password you can easily remember. It must be at least 6 characters long.  

Make up a password:
  -- keep this private!
Enter password again:
 -- for verification

If you do not want to receive any information on new discounts, products and services, click to remove check mark  

Yes, I am interested in receiving information about new  products, services and insurance discounts.

 

 
 

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All information and images are copyrighted. Revised 07/26/06