Membership Application
 
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1.
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2.
Mailing Address*
 

 

 

 

 

 

 
 
 
 
3.
Physical Address (If Different from Above)
 

 

 

 

 

 

 
 
 
 
4.
Type of Business*
 
 
 
 
 
 
 
 
 
 
5.
Membership Contact Person*
 
     
Name    
 
 
 
6.
*
 
 
 
 
7.
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16.
*
 
 
 
 
  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*
 
 
 
 
 
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