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Membership Application
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Membership Dues
Enter Company ID number
Apply
IS YOUR COMPANY ALREADY IN THE DATABASE? –
If you have been receiving communications from CIC-DC your company’s information may already be in our database. Enter your Company ID number in the box
ABOVE
, click submit, and your CIC-DC Membership Application automatically populate with your company’s information. If you do not know your Company ID Number, you can obtain it by contacting CIC-DC headquarters at 888.302.4232.
IF YOUR ORGANIZATION IS ALREADY A MEMBER OF CIC-DC
and you would like to become an additional CIC-DC member contact, use your Company ID Number to enter your personal contact information. You can obtain your Company ID Number through the CIC-DC contact person within your organization or by calling CIC-DC headquarters at 888.302.4232
.
Membership Type
*
select a membership type
Affiliate Member - $400.00
Captive Insurance Co. (Corp. & Assoc.) Member - $500.00
Captive Insurance Co. (If formed by Non-Profit Entity) Member - $350.00
Industry Service Provider Member - $750.00
Choose Company Password
IS YOUR COMPANY NEW TO CIC-DC?
If this is the first contact your company has made with CIC-DC, first select a Membership Type and choose a company password
ABOVE
before completing the bottom portion of the Membership Application.
If someone else within your organization would like to become an additional CIC-DC contact, submit your information on this application
FIRST
and then have the additional contact complete the top portion of this page
using your Company Password to log-in or
when a Company ID Number has been assigned to you.
Next
Contact Information
Contact Information
Email
*
Confirm email address
*
Prefix
First Name
*
Middle
Last Name
*
Suffix
Title
*
Informal Name
Company
*
Address Line 1
*
Address Line 2
Address Line 3
City
*
State/Province
select a state
AB - Alberta
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
BC - British Columbia
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MB - Manitoba
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NB - New Brunswick
NC - North Carolina
ND - North Dakota
NE - Nebrasks
NF - Newfoundland
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
ON - Ontario
OR - Oregon
PA - Pennsylvania
PE - Prince Edward Island
PQ - Quebec
PR - Puerto Rico
RI - Rhode Island
SC - South Carolina
SD - South Dakota
SK - Saskatchewan
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VT - Vermont
WA - Washington
WI - Wisconson
WV - West Virginia
WY - Wyoming
Zip/Postal Code
*
Country
select a country
United States
Afghanistan
Ă…land Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo - The Democratic Republic Of The
Cook Islands
Costa Rica
Cote D'ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran - Islamic Republic Of
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea - Democratic People's Republic Of
Korea - Republic Of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia - The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia - Federated States Of
Moldova - Republic Of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory - Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts And Nevis
Saint Lucia
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia And Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania - United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands - British
Virgin Islands - U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Website
*
Phone
*
Alternate Email
Include me in Membership Directories
*
Yes
No
Include me in Broadcast Email
*
Yes
No
Next
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Additional Information
Additional Information
Membership dues are non-refundable.
*
Yes, I agree.
Type of Business
*
select one
1 - Single Parent Captive Program
2 - Association Sponsored Captive Program
3 - Risk Retention Groups
4 - Industry Service Provider
5 - Press/Government
6 - Other
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Payment Details
Payment Details
Apply
Total Amount Due
$
Payment Method
Select a Payment Method
Visa
Mastercard
American Express
Discover
Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.
Account Type
Checking
Savings
Routing Number
Account Number
Account Holder Type
Business
Personal
Business Name
Account Holder Name
By submitting payment, I am authorizing Captive Insurance Council of the District of Columbia to initiate a single or recurring ACH/electronic debit in the amount indicated from the bank account I designated above. I understand that this Authorization will remain in full force and effect until the transaction is cancelled by me by contacting Captive Insurance Council of the District of Columbia, or the ACH/electronic debit is processed from the designated account. I certify that (1) I am authorized to debit the bank account above and (2) the ACH/electronic payment I am authorizing complies with all applicable laws.
Name on Card
Card Number
Expiration
01 - January
02 - February
03 - March
04 - April
05 - May
06 - June
07 - July
08 - August
09 - September
10 - October
11 - November
12 - December
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
CSC
Billing Street
Billing Zip Code
Enable Automatic Renewals?
*
Select
"Yes"
to enroll in automatic membership renewal. The payment method submitted with this form will be used for your future membership renewals. You can change the automatic renewal setting or saved payment method at any time in either the "Payment Methods" or "Renewal Settings" where you edit your profile.
Yes
No
Submit
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UPCOMING EVENTS
Annual Conference
November 8-9, 2023
InterContinental Washington,DC
The Wharf