Tuesday, May 21, 2013

Membership Application

Thank you for your interest in membership with the Missouri Self-Insurers Association.  Please fill out the form below to apply for membership.  After you submit your application, we will review the information and set up your account.  You will be given the option to pay membership dues immediately via Paypal, phone, or postal mail.

Organization : *
First Name : *
Last Name : *
Contact Address : *
 
City : *
State : *
Zip : *
Work Phone : *
Mobile Phone :
Fax Number :
Email : *
Website :

Select the type of membership you are interested in:

Member Type : *
Employees : *(number Of Missouri self-insured employees)
Services Provided :

Pricing for Active Membership

Number of EmployeesAnnual Dues
1-500$150.00
501-1000$250.00
1001-3500$275.00
3501-5000$350.00
5001-7500$450.00
7501-10000$600.00
10001-∞$800.00

Pricing for Affiliate Membership

Number of EmployeesAnnual Dues
1-500$100.00
501-1000$150.00
1001-3500$175.00
3501-4500$225.00
4501-7500$275.00
7501-10000$375.00
10001-∞$500.00

Pricing for Associate Membership

Number of EmployeesAnnual Dues
1-∞$500.00
Desired Username : *
Password : *
Re-enter Password : *
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