New Jersey 
Captive Insurance Association

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.

Copyright ©2010 New Jersey Captive Insurance Association, LLC.  All Rights Reserved.  Send inquiries or suggestions to info@njcia.org.

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