2024 Fall Conference Registration

2024 Fall Conference Registration

Step 1 of 2

50%

Registration Information

Type of Registration(Required)

Are You a Member of MSIA?(Required)

To View MSIA's Membership List Go To: https://michselfinsurers.org/membership-list/

Industry Category(Required)

Self-Insured Employer or Group Fund (Self-Insured) (Member)

Price:

Self-Insured Employer or Group Fund (Self-Insured) (Non-Member)

Price:

Number of Registrations

Additional Registrants Information

If you are purchasing more than 1 registration, please provide the Name, Title, and E-Mail Address for each additional attendee:

Number of Registrations

Additional Registrants Information

If you are purchasing more than 1 registration, please provide the Name, Title, and E-Mail Address for each additional attendee:

Vendor (Provider, TPA, PI, IME, NCM, Other) (Member)

Price:

Vendor (Provider, TPA, PI, IME, NCM, Other) (Non-Member)

Price:

Number of Registrations

Additional Registrants Information

If you are purchasing more than 1 registration, please provide the Name, Title, and E-Mail Address for each additional attendee:

Number of Registrations

Additional Registrants Information

If you are purchasing more than 1 registration, please provide the Name, Title, and E-Mail Address for each additional attendee:

Attorney (Member)

Price:

Attorney (Non-Member)

Price:

Number of Registrations

Additional Registrants Information

If you are purchasing more than 1 registration, please provide the Name, Title, and E-Mail Address for each additional attendee:

Number of Registrations

Additional Registrants Information

If you are purchasing more than 1 registration, please provide the Name, Title, and E-Mail Address for each additional attendee:

Sponsorship Opportunities

Diamond Sponsor $1,850.00

Platinum Sponsor $1,350.00

Gold Sponsor $1,100.00

Silver Sponsor $700.00

Breakfast Sponsor $550.00

Lunch Sponsor $550.00

Break Sponsor $400.00

Diamond Sponsor

Price:

Platinum Sponsor

Price:

Gold Sponsor

Price:

Silver Sponsor

Price:

Breakfast Sponsor

Price:

Lunch Sponsor

Price:

Break Sponsor

Price:

Logo

Please Upload A JPEG Or PNG Of Your Company Logo

Max. file size: 300 MB.

Additional Registrants Information

The Diamond Sponsorship Level Includes 3 Total Attendee Registrations. Please Provide the Name, Title, and E-Mail Address for each additional attendee:

Additional Registrants Information

The Platinum Sponsorship Level Includes 2 Total Attendee Registrations. Please Provide the Name, Title, and E-Mail Address for each additional attendee:

Exhibitor (Member)

Price:

Do You Need To Purchase Registration(s) For Additional Representatives?

Exhibitor Booth Registration Includes 1 Representative

Yes

Additional Representative (Member)

Price:

Number of Additional Registrations

Additional Registrants Information

If you are purchasing more than 1 registration, please provide the Name, Title, and E-Mail Address for each additional attendee:

Exhibitor (Non-Member)

Price:

Do You Need To Purchase Registration(s) For Additional Representatives?

Exhibitor Booth Registration Includes 1 Representative

Yes

Additional Representative (Non-Member)

Price:

Number of Additional Registrations

Additional Registrants Information

If you are purchasing more than 1 registration, please provide the Name, Title, and E-Mail Address for each additional attendee:

Do You Plan to Attend the Reception After the Conference?(Required)

The reception will be taking place at Cantoro Trattoria (15550 N Haggerty Rd, Plymouth, MI 48170) immediately following the conference until 6 pm. Food will be provided by Team Rehabilitation and Entech Medical Staffing; a cash bar will be available. Space is limited.

Yes

If You Are Registering More Than One Person, Are Your Additional Attendees Planning to Attend the Reception After the Conference?

Yes, All Attendees

Yes, But Not All Attendees

Please List the Names of the Attendees That Do Plan to Attend

Registration Total

Will You Be Paying By Credit Card or Do You Need To Be Invoiced?

Credit Card

Invoice

Company(Required)

Name(Required)

First Last

Job Title(Required)

E-Mail Address(Required)

Phone Number(Required)

Payment Information

Total

Credit Card

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing E-Mail

If you are paying by Credit Card this will be the E-Mail that will receive the transaction receipt.

Billing Phone Number

Payment Information

If you are paying via Invoice you will receive an E-Mail from our Event Partner, mary@associationguidance.com, to confirm your registration and they will send you an invoice.

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing E-Mail

If you are paying via Invoice this will be the E-Mail that will receive the Invoice.

Billing Phone Number

*All cancellations will be subject to a fee of 10% of the total purchase price.

Questions? Please e-mail our Event Planner at mary@associationguidance.com or call us at 517-333-3628