Membership Application or Renewal

New Application or Renewal

New Member Application

Membership Renewal

Membership Category (Select One)

ACTIVE Any person, firm, public entity, or corporation organized to or which conducts a business, whether or not for profit, and which is a self-insurer.

PROFESSIONAL Any person, firm, business, or corporation which provides workers' compensation related services to or which represents self-insurers.

AFFILIATE Any association or group of employers which is a recognized self-insurer or the parent or subsidiary of a corporation affiliated with an active member or former self-insured.

Company Name *

Nature of Business *

Contact Name *

Referred By

Address *

Address

City

State/Province

Zip/Postal

Email Address *

Enter Email

Confirm Email Address *

Confirm Email

Phone Number *

Membership Fees

Dues

$350

Questions or Concerns?

If you have any questions regarding membership, please contact Heidi Mahoney, NYSIA Secretary, phone: 716-668– 0822; fax: 716-668–5035; e-mail: secretary@nyselfinsurance.com. Make checks payable to: New York Self-Insurers Association, and mail application to the address at the top of this page or charge to your credit card.

Click here for a PDF Version of NYSIA Application for Membership, or contact us and we will mail you an application.

Membership Application or Renewal

Application for Membership or Renewal

Membership Fees

Questions or Concerns?