http://www.selfinsurers.com - 2009-10 Membership Application

2009-10 Membership Application

The 2009/10 Application For Membership or Membership Renewal
of NSW Worker's Compensation Self Insurers' Association

(Tax Exempt)

Please Note: All fields marked with an astericks (*) are required

Company Details
Company Name:
Street Address:
City/Postcode:

* Hereby renew our membership as a:
	- Full Member [$750.00] (Licensed NSW Self-Insurer)
	- Associate Member [750.00] (Specialised NSW Insurer)
	- Provisional Member [$900.00] of the NSW Workers’ Compensation Self Insurers Association Incorporated (an organisation currently investigating benefits of self-insurance or an organisation self-insured elsewhere in Australia or an organisation which has previously held a self-insurer licence and is currently managing claims incurred under that licence or an organisation which was already a “non-member” at the time of incorporation and has not ceased to be a member of this category)

Principal contact details
	Same as above
Address:
Suburb/City
State/Postcode:
Phone No:
Fax:

PAYMENT DETAILS *
* I/We will be paying a total of $
* By the follow means:	(please tick)	Cheque EFT

Company Representatives
Please nominate up to two Company Representatives and a third as an additional Representative for OH&S matters. Company representatives must be employees of the member.
	Primary contact
1.	* Name:
	* Job Title:
	* Phone:
	* Email:
	Secondary contact
2.	Name:
	Job Title:
	Phone/Mobile:
	Email:
	- OH&S contact
3.	Name:
	Job Title:
	Phone/Mobile:
	Email:

Authorisation
	Authorised by:
* Name:
* Date: (00/00/00)
Please type in the characters you see below.

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* For Electronic Funds Transfer (EFT)
Our account details are as follows:
NSW Workers Compensation Self-insurers Association
Community First Credit Union (Ph: 1300 132 277)
BSB: 802 038 Account: S7 Depositor Number: 514833

If you choose to print and mail this form...
Please complete and return, marked to the attention of:
Paul Bransdon, Treasurer, NSW Workers’ Compensation Self Insurers Assoc. Inc.
Fax: (02) 9663 4203
Email: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

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