2010 ASSOCIATE MEMBER - RATING ORGANIZATION APPLICATION

Join WCRI | Research Programs | Governance

Benefits of Membership | WCRI Members
Apply for Membership | Membership Categories

Join WCRI

Apply for Membership

Workers Compensation Research Institute

2010 ASSOCIATE MEMBER – RATING ORGANIZATION APPLICATION

Our organization would like to become an associate member - rating organization of the Workers Compensation Research Institute. We have read the material describing WCRI, including the Bylaws, and agree to the terms of membership.

The membership application form may be completed in two ways.

An application form may be completed and submitted on line.
An application form may be completed, printed and mailed to the Institute.

Please complete all fields on the application form, including the Primary Contact on the Member Distribution list, before submitting the application.

ORGANIZATION:
ADDRESS:
ADDRESS 2:
CITY:
STATE:
ZIP:
PHONE:
FAX:

DATES OF MEMBERSHIP: from January 1, 2010 to December 31, 2010

SUBMITTED BY:
DATE:

Rating organizations are encouraged to join WCRI as associate members. Membership does not include either voting privileges or a role in the governance of the Institute.

Annual Fee: $5,000 per state in which authorized/licensed. Maximum assessment $25,000.

Member Distribution List

In order that we may disseminate information about the Institute and our research to the appropriate people within your organization, please designate those who should receive our communications.

The Primary Contact is our contact within your organization. This person automatically receives one copy of each major publication. All individuals listed receive WCRI FLASHREPORTS and other electronic communications keeping those on your list informed in advance of the latest WCRI research.

Primary Contact:
Name:
Email address:
Title:
Company address:
City:
State:
Zip:
Phone Number:

Alternate Contact:
Name:
Email address:
Title:
Company address:
City:
State:
Zip:
Phone Number:

Please check to see that all information is correct and then click Submit Application. We will invoice you for the assessment fee.

If paying by check, please print this form and mail with the payment to the address below.

Workers Compensation Research Institute
955 Massachusetts Avenue
Cambridge, MA 02139

For further information, please contact WCRI at 617-661-9274 or email us at wcri@wcrinet.org.

955 Massachusetts Avenue Cambridge, Massachusetts 02139 617-661-WCRI (9274)