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