Association of insurance adjusters and associated service providers
Membership Application
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Membership Application

MEMBERSHIP APPLICATION

NAME:

COMPANY NAME:

BUSINESS ADDRESS:

CITY:

STATE:

ZIP:

OCCUPATION OR TITLE:

HOME ADDRESS:

CITY:

STATE:

ZIP:

BUSINESS PHONE:

HOME PHONE:

E-MAIL ADDRESS:

CHECK HERE AUTHORIZING E-MAIL SUBMISSIONS OF WCCA BUSINESS

MAIL TO BE RECEIVED AT:
HOME ADDRESS
BUSINESS ADDRESS

STATUS:

$25 PER PERSON (ADJUSTER) PER YEAR
$250 CORPORATE (ADJUSTING FIRM OR INSURANCE COMPANY) PER YEAR
$50 PER PERSON (VENDOR) PER YEAR
$500 CORPORATE (VENDOR) PER YEAR

TOTAL PAYMENT DUE

MAIL ALL PAYMENTS TO:
POST OFFICE BOX 23992, TAMPA, FLORIDA 33623

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