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Self-Insurance PAC Communication Authorization Form


Why we need your authorization: Current Federal election law requires trade associations to obtain permission from its member companies before designated representatives may receive information about or be solicited for contributions to the association’s Political Action Committee.


First Name *
Middle Initial
Last Name *
Company *
Company Address *
Company City *
Company State *
Company Zip *
Telephone *
Email *

Please sign your name and insert your company name beside each year for which the Self-Insurance PAC may solicit contributions. You may give your permission for up to the next five years.

2019 *

By selecting "I Agree" I affirm that the name typed above represents my official signature. I hereby authorize the Self-Insurance PAC to communicate with my company during the calendar year(s) indicated. Please note that the Self-Insurance PAC will never directly contact or solicit your employees or directors without your additional written consent.

I Agree

Federal law permits a corporation to approve employee solicitation to only one trade association PAC in a calendar year.