Membership Application - Self-Insurance Institute of America, Inc.

Online Self-Insured Employer Membership Application

Membership Dues

Enter Company ID number

IS YOUR COMPANY ALREADY IN THE DATABASE? – If you have been receiving communications from SIIA your company’s information may already be in our database. Enter your Company ID number in the box ABOVE, click submit, and your SIIA Membership Application automatically populate with your company’s information. If you do not know your Company ID Number, you can obtain it by contacting SIIA headquarters at 800.851.7789.

IF YOUR ORGANIZATION IS ALREADY A MEMBER OF SIIA and you would like to become an additional SIIA member contact, use your Company ID Number to enter your personal contact information. You can obtain your Company ID Number through the SIIA contact person within your organization or by calling SIIA headquarters at 800.851.7789.

Your Dues Rate Type is: Employer Member $500.00

Choose Company Password

IS YOUR COMPANY NEW TO SIIA?
If this is the first contact your company has made with SIIA, first select a Membership Type and choose a company password ABOVE before completing the bottom portion of the Membership Application.

If someone else within your organization would like to become an additional SIIA contact, submit your information on this application FIRST and then have the additional contact complete the top portion of this page using your Company Password to log-in or when a Company ID Number has been assigned to you.

Contact Information Contact Information

Email *

Confirm email address *

Prefix

First Name *

Middle

Last Name *

Suffix

Title *

Informal Name

Company *

Address Line 1 *

Address Line 2

Address Line 3

City *

State/Province

Zip/Postal Code *

Country

Website

Personal LinkedIn URL

Phone *

Alternate Email

Include me in Membership Directories *
Yes No

Include me in Broadcast Email *
Yes No

Additional Information Additional Information

Type of Business *

Self-Insured Entity is defined as an organization that is self-insured for group health care and-or workers compensation or is a captive insurance company-risk retention group. This also includes employers considering self-insurance-captive insurance. Self-insurance industry service providers including but not limited to TPAs MGUs & captive management companies do not quality for this membership rate even if their organization is self-insured. Membership submitted by service providers selecting the employer rate will not be processed. *
Yes my company falls under the guidelines of an Employer-Self-Insured Entity.

Member Sections (Choose all that apply): *

How Did You Find Us?

Payment Details Payment Details

Amount to Charge :

Payment Method:

Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.

Bank Name:
Bank Account Holder Name:
Routing Number:
Account Number:
Account Type:

Name on Card:

Card #:

Expires:

CSC (What's this?):

Enable Automatic Renewals?

Select "Yes" in order to be enrolled in automatic membership renewal. The above payment method will become your saved payment method, overwriting anything that may have been previously saved and will be used for future renewals. You can change the automatic renewal setting or saved payment method at any time in either the "Payment Method" or "Membership Auto-Renewal" tabs where you edit your profile.

No Yes