Webinar Registration

Webinar Registration Form

Are you a member of MSIA?(Required)

If you are unsure if you or your company is a member you can view our up to date member list at https://michselfinsurers.org/membership-list/

Yes

What type of member are you/your company?

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

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

Attorney

Total

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

Credit Card

Invoice

Name(Required)

First Last

Company Name(Required)

Title

E-mail(Required)

If you would like to register multiple people from your company, please list their names, titles, and e-mail addresses:

CAPTCHA

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Billing E-mail

You will receive a transaction receipt to the email provided.

Billing Address

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

Name

First Last

Billing E-mail

You will receive an invoice at the email provided.

Billing Address

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