Annual Membership Registration Form

Member Organization Information

Organization Name(Required)

Representative Name(Required)

First Last

Company Address(Required)

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

Phone(Required)

Email(Required)

Company Website

Description of Product or Service

Annual Membership

Type of Membership(Required)

For "Attorney" membership, the membership is for an individual and will not include anyone else from your firm. For "Self-Insured Employer or Group Fund" and "Vendor" memberships, the membership applies to all employees within your company.

Additional Employees

If additional employees would like to receive MSIA conference information, please provide name and email address. Please add 1 employee per line: (Name, Email)

Additional Employees

If additional employees would like to receive MSIA conference information, please provide name and email address. Please add 1 employee per line: (Name, Email)

Transaction Details

Order Total

Order Total Reflects Proated Membership Dues

Payment Method(Required)

Pay by Check (You will receive an Invoice)

Pay by Credit Card

Email(Required)

If paying by check this is where we will send an invoice.

Billing Address(Required)

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

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Join MSIA

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

Annual Membership Registration Form

Member Organization Information

Annual Membership

Transaction Details

Questions? Reach out to Association Guidance, our Event Partner, at 517-333-3628, or email us at MISelfinsurers@gmail.com.