| Company type (select
one)* |
Life Insurance
Co. Non-Life Insurance Co.
Other
University Tech/Consulting |
|
Company* |
|
| Street Address* |
|
| City |
|
| Country* |
|
Postal
Code |
| Mailing Address (if
different) |
|
| City |
|
| Country |
|
Postal
Code |
| Telephone #* |
|
|
Country Code/City Code/Local # |
| Fax #* |
|
|
Country Code/City Code/Local # |
|
Company
Web Site |
|
|
Annual Life Premium Income (check
appropriate description below)
|
|
|
Less than US$60 million
|
|
|
US$60
million or greater, but less than
US$250
million
|
|
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US$250
million or greater
|
|
|
We
are not a Life Insurance Company, Annual Life Premium Income Does Not
Apply
|
|
|
This information is confidential and
will not be shared with other members or organizations. This
information is confidential and used for the calculation of the LOMA membership dues
only.
|
| Completed by:* |
|
| Job Title |
|
Email Address |
| How did you find out about
LOMA? |
prior knowledge
trade show
trade
publication
conference/workshop
internet/ website
former employee of member
company other
|
|
Please check the appropriate box(es) that applies to your
request:
Please send me an
estimate for membership dues.
Please send me more information on membership
benefits.
Neither of
these apply to me. Please see comment box
below.
COMMENTS:
|
Contact
Information:
LOMA
International Division
2300 Windy Ridge Parkway
Suite 600
Atlanta, GA 30339-8443
United States
Phone: 1 770 984-6434
Fax: 1 770 984-6420
If you
have any questions, please send an email to intl@loma.org.
| |