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

Membership Dues

Enter Company ID number

Your Dues Rate Type is: Employer Member $500.00

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Contact Information

Email *

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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

Membership dues are non-refundable. *
Yes, I agree.

Type of Business *

If you answered other please enter below. *

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

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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.

Account Type

Checking

Savings

Routing Number

Account Number

Account Holder Type

Business

Personal

Business Name

Account Holder Name

By submitting payment, I am authorizing Self-Insurance Institute of America, Inc. to initiate a single or recurring ACH/electronic debit in the amount indicated from the bank account I designated above. I understand that this Authorization will remain in full force and effect until the transaction is cancelled by me by contacting Self-Insurance Institute of America, Inc., or the ACH/electronic debit is processed from the designated account. I certify that (1) I am authorized to debit the bank account above and (2) the ACH/electronic payment I am authorizing complies with all applicable laws.

Name on Card

Card Number

Expiration

CSC

Billing Street

Billing Zip Code

Total Amount Due

Online Self-Insured Employer Membership Application

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