Membership Application

for Companies in the U.S. and Canada that DO NOT

    Underwrite Life Insurance

 

It's easy. Just complete the application online and click on the submit button. 
Your application will be sent directly to LOMA's membership area.  If you prefer, you may mail or fax the completed application to LOMA at the address and fax number provided below.  Please contact the member relations team to request a membership dues quote by calling: 770 984-3744 or email: members@loma.org. 

 

Section I   Must be completed by all applicants

Company 
Street Address
City

State/Province

Zip
Mailing Address (if different)
City

State/Province

Zip
Phone No.
             Ext.

Fax No.

Company Web Site
President or CEO 
E-mail

Chief Financial Officer 
E-mail 

Chief Human Resources Officer
E-mail 

Chief Information Systems/Technology Officer

E-mail 
Does another company own you? 
If yes,  whom?
Company Type of Business
Primary Products/ Services Offered
Total Company Revenue (check appropriate description below)   

Less than $2 million

$2 million or greater, but less than $50 million

$50 million or greater, but less than $500 million

$500 million or greater
5% GST also applies to Canadian companies.

*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.  
How did you hear about LOMA?

Prior Knowledge Trade Show  Member Company  Employee  Internet/Web Site 

Conference/Workshop  Trade Publication   LIC     LIIC

Other.  Please tell us how you heard about LOMA

Please list subsidiary companies that should be included in your membership.

Company Name: 

Company Address: 

Company Contact Person:

Company Name: 

Company Address: 

Company Contact Person:

Company Name: 

Company Address: 

Company Contact Person:

Application completed by:

Title: 

E-mail: 

 

Section II (Optional)

Please indicate if you would like information on LIC or LOMA Canada.  Your company must be a LOMA member in order to qualify for an LIC or LOMA Canada membership.

LIC (Life Insurers Council) provides information, services and programs that provide small and medium sized companies, regardless of distribution system, the knowledge to increase their bottom line profitability, especially in the underserved market.

 

LOMA Canada - Representing a major portion of Canada's life and health insurance industry. LOMA Canada serves the educational and professional development needs of our member companies and their employees.

If you have any questions regarding this application, please contact:
 Membership Dues Analyst, LOMA, 2300 Windy Ridge Parkway, Suite 600, Atlanta, GA 30339-8443, 
Telephone: 770-984-3744,

 Fax: 770-984-6415 or e-mail: members@loma.org