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IAIR
c/o The Beaumont Group, Inc.
3626 East Tremont Avenue - Suite 203
Throggs Neck, NY 10465
Tel: (718) 892-0228
Fax: (718) 892-2544
Attention: Maria Sclafani
mcs@thebeaumontgroup.com

2009 APPLICATION FOR MEMBERSHIP

First Name:		Last Name:
Company Name:		Title:
Business or Organization Type		Orientation of Practice
Business Address:		Suite:
City:		State:
Zip:		Country
Telephone:		Fax:
Cell Phone:
Company Web Site:		Email Address:
Personal Information
Address:		Apt:
City:		State:
Zip:		Country:
Telephone:		Fax:
Degrees Achieved:

AIR Designations Achieved

Please indicate AIR Designations achieved. Check all that apply

AIR		CIC
AIR-Reinsurance		AIR-Asset Management
AIR-Accounting/Financial Reporting		AIR - Claims/Guaranty Funds
AIR-Legal

Please List Your Other Professional Designations

Deputy Receivership
Do you accept appointments as a contract deputy receiver, or otherwise contract for work for special deputy receivers or insurance regulators or supervising courts (or functionally equivalent appointment) in the receivership area?

Functional Areas

Please indicate the functional areas of your Receivership Experience.

Accounting/Finance		Actuary
Administrative Supervision		Claims
Closing Estates		Information Technology
Expert Witness		Guaranty Funds
Investment & Asset Mgt Recovery		Litigation/Legal
Litigation Support		Rehabilitation
ReInsurance		Takeover/Estate Management

Experience

Please indicate the types of your Insurance Receivership Experience. Check all that apply

Fraternals		HMO
Life		METS & MEWAS
Other		P&C
Professional Reinsurer		Risk Purchasing Group
Unauthorized Insurer

Primary Locations of Practice

Please select Primary Locations of Practice below. Check all that apply

Alaska		Alabama
Arkansas		Arizona
California		Colorado
Connecticut		District of Columbia
Delaware		Florida
Georgia		Hawaii
Iowa		Idaho
Illinois		Indiana
Kansas		Kentucky
Louisiana		Massachusetts
Maryland		Maine
Michigan		Minnesota
Missouri		Mississippi
Montana		North Carolina
North Dakota		Nebraska
New Hampshire		New Jersey
New Mexico		Nevada
New York		Ohio
Oklahoma		Oregon
Pennsylvania		Puerto Rico
Rhode Island		South Carolina
South Dakota		Tennessee
Texas		Utah
Vermont		Virginia
Washington		Wisconsin
West Viginia		Wyoming
Virgin Islands

Felony Involvement
Have you ever been involved in a felony involving dishonesty or breach of trust?

Membership Oath
The objectives of the International Association of Insurance Receivers are to:

1. promote high standards in the administration of insurance receiverships and the prompt and efficient closing of receiverships;
2. promote a uniform code of professional standards for insurance receivers;
3. promote a uniform code of ethical standards for insurance receivers;
4. develop educational and training programs to enhance the qualifications of persons working in the field of insurance receiverships and provide a forum for discussion of subjects of common interest to them;
5. inform the public of the value of highly-trained and professional insurance receivers who are granted permission to use the Association's designations, thereby to cause insurance receivers to aspire to the highest standards;
6. provide benefits usually available to organizations whose members have common interests; and
7. perform such other acts and carry on such other lawful activities as may be incidental to, or as may be neccesary or convenient to effectuate, the foregoing purposes and objectives.

By checking here, I agree to support the furtherance of the purpose and objectives of the Association.

Please Note

Please Note: In addition to submitting this application via E-mail, your dues and a personal resume must also be mailed to the executive director whose address may be found on the "Contact Us" link at the bottom of this page.

DUES STRUCTURE AND PAYMENT OPTIONS

ANNUAL DUES:
For Profit Organizations: $275 per person
Not For Profit Organizations: $125 per person

Group Discounts: IAIR offers a discount to organizations with more than 3 members as follows:

Number of Members For Profit Organizations Not For Profit Organizations

1 - 3 Members $275/member $125/member

4 - 9 Members $225/member $100/member

10 or more Members $175/member $75/member

(If this application is not accepted, money will be returned.)

A full year's dues must accompany this application: Fiscal year: January 1 to December 31.

STATEMENT: "Contributions or gifts to the International Association of Insurance Receivers are not deductable as charitable contributions for federal income tax purposes. Dues payments are deductible by members as an ordinary and necessary expense." Section 10701 of the Revenue Act of 1987.

PAYMENT METHOD: Please select a payment method below:

I would like to pay by entering my credit card information and submitting it with this application. (Please note this form is a secured page.)
I would like to mail a check to the Executive Director.

Payment by Check: Payable to IAIR, (Fed. I.D. No. 51-0335737) and mailed to: IAIR, C/O The Beaumont Group, Inc. 555 Fifth Avenue, 8th Fl., New York, NY 10017 (US Dollars Only)

I will be forwarding a check in the amount of $

CREDIT CARD PAYMENT: If you selected to pay by credit card above, then please complete the information:

Payment Amount:

Cardholder's Name:

Card Billing Address:

Credit Card Number:

Card Type:

Expiration Date:

Security Code:

Authorization
By providing the above information, you agree that IAIR may charge U.S. $275.00 or the appropriate discounted dues amount to this credit card.

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