Application for Membership or RenewalMembership or Renewal Application New Application or Renewal New Member Application Membership RenewalMembership 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 Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal 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. If you are human, leave this field blank. Δ
