VCIA - Apply for Membership

Membership Category:

Please note: Membership dues are deductible as a business expense. The estimated non-deductible portion of your dues to be expended on lobbying efforts is 20%. For more information regarding Federal Law, please contact your tax advisor.

First Name* Middle Initial* Last Name* E-mail* Title*

Captives: Please enter name of Captive Insurance company, not parent company

Company* Parent Company Industry Type (Captives only) Address* Address 2 City* State/Province* Zip/Postal Code* Country* Main Office Phone* Direct Phone & Ext.* Fax

Captives Only Parent Company Date license issued Type of captive Management company Domicile

Affiliates Only Sponsored captive cell (specify name of the sponsored) Foreign or alien captive (specify name of domicile) Related legal entity of a current Full Captive Member (related company name) Other interested parties (non-service providers). Examples, students, non-service providers looking into formation of a captive. Note: Service providers only qualify as Associate Members

If you are an Associate member and would like to appear in our online directory, please provide a 25 word narrative of your areas of expertise and describe the services and/or products provided by your firm. This narrative will be placed on the VCIA website in the "Captive Services Directory" area.

Captive Services Directory for Associate Members Company Website (url address): for link from the Captive Services Directory

If you are a service provider, please indicate in which categories of the Captive Services Directory you would like to have your company listed. Please indicate a maximum of three categories below

Captive Services Directory Categories Category 1 Category 2 Category 3

Payment Options Payment Options: Credit card type Credit Card Number Expiration Month Expiration Year Name as it appears on card