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UCIA Membership Form
Utah Captive Insurance Association Membership Application
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* Indicates required question
Applicant Full Name
*
Your answer
Company/Association
*
Your answer
Role/Position
*
Your answer
Email
*
Your answer
Phone
*
Your answer
Website Address
Your answer
Full Company Address
*
Your answer
For demographic data purposes, please indicate all that may apply to your company:
*
Actuarial
Agent and Broker (Producer)
Claims Management
Fronting Insurance Company
Independent Auditors
Information Technology
Insurance Accounting
Insurance Consulting
Insurance Program Management
Insurance Managing General Agent
Insurance Managing General Underwriter
Captive Manager
Captive Owner
Legal Service
Loss Control Services
Publication
Regulating Authority
Reinsurance Company
Reinsurance Intermediary
Risk Management
Specialized Products and Services
Trade Associations
TPA
Other:
Required
Date your company was organized
MM
/
DD
/
YYYY
Years the applicant has been directly involved in the captive industry
Your answer
Other related associations/organizations you, or your firm is currently a member
Your answer
Your principal purpose for joining the UCIA
Your answer
Do you want your information featured on the UCIA website at www.utahcaptive.org?
*
Yes, please
No, thank you
Other:
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