Membership Application

Page 1 of 1     1. Company Name*         2. Mailing Address*   Street Address   Street Address Line 2   City   State/ Province   Zip Code   Country         3. Physical Address (If Different from Above)   Street Address   Street Address Line 2   City   State/ Province   Zip Code   Country         4. Type of Business*   Group Self Insured Fund   Self Insured Employer   Third Party Administrator   Associate (Law Firms and Related Services)   Insurance Company/ Reinsurance Company   Deductible Policy Employer   Associations       5. Membership Contact Person*       First Name   Last Name Name           6. Title*         7. Phone Number*         8. Fax*         9. Toll Free         10. Cell Phone         11. Company's Website*         12. Number of Louisiana Employees         13. Year Established         14. Year Established         15. Louisiana Cities Served         16. Please provide a 15-50 word synopsis of the services provided by your company to be used in the Membership Directory. If you need to include more detail, email the LASIE office an attachment version of your description.*           Annual Membership Dues: Group Self Insurance Fund (Manual premium of $3 million or greater) | $2,700.00 (Manual premium of less than $3 million) | 1,600.00 Self Insured Employer | $450.00 Deductible Policy Employer | $ 450.00 Third Party Administrator | $450.00 Insurance Company/ Reinsurance Company | $450.00 Associate (Law Firms and Related Services) | $350.00 Associations | $450.00         Please make out check and mail dues payment to LASIE PO Box 4151 Baton Rouge, LA 70821-4151       17. Payment*   Receive Check Invoice   Receive Credit Card Invoice