Southern Loss Association Application for Membership 2023

Application For Membership

• * First Name:
• * Last Name:
• * Address 1:
• Address 2:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• * Email Address:
• * Confirm Email Address:

• Fee

  Type	Fee
  Event fee	$45.00
  Event fee type 2	No Charge

• * Company:
• * Job Title:
• * Job description:

• * What percentage of your time is devoted to the handling of insurance claims?
• * How does your job relate to the insurance industry?

Sponsor Information

• * Name of sponsor:
• * Sponsor's employer:
• * Contact telephone number:
• * E-mail address: