Charter
Membership Application
Charter Membership Application Form.doc
Company/Association:___________________________________________________________________
Address:______________________________________________________________________________
Primary Contact / Title / Telephone:________________________________________________________
Email
:____________________________________________
Website:
__________________________________________
Primary
Industry of
Applicant:_____________________________________________________________
Membership Categories
and Dues (please check box):
[
] Founding Member: $7,500 (2 years)
[
] Captive Member: $750 annually
[
] Associate Member (service
provider): $1,000 annually
[
] Contributing Individual Member
$500 or less
Checks may be mailed to:
New
Jersey Captive Insurance Association
P.O. Box 202
Mahwah, NJ 07430
Upon receipt of your application and dues,
you will be contacted to schedule an interview that will create your Member Profile. Your profile will be used by the association
to identify, actuate, and monitor your membership satisfaction and return on
investment.
