Membership Application | Montana Captive Insurance Association, Inc.

Membership Dues

Enter Company ID number

IS YOUR COMPANY ALREADY IN THE DATABASE? – If you have been receiving communications from MCIA your company’s information may already be in our database. Enter your Company ID number in the box ABOVE, click submit, and your MCIA Membership Application automatically populate with your company’s information. If you do not know your Company ID Number, you can obtain it by contacting MCIA headquarters at 866.388.6242.

IF YOUR ORGANIZATION IS ALREADY A MEMBER OF MCIA and you would like to become an additional MCIA member contact, use your Company ID Number to enter your personal contact information. You can obtain your Company ID Number through the MCIA contact person within your organization or by calling MCIA headquarters at 866.388.6242.

Membership Type *

Choose Company Password

IS YOUR COMPANY NEW TO MCIA?

If this is the first contact your company has made with MCIA, 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 MCIA 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.

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

Zip/Postal Code *

Country

Website *

Phone *

Alternate Email

Include me in Membership Directories *
Yes No

Include me in Broadcast Email *
Yes No

Additional Information

Membership dues are non-refundable. *
Yes, I agree.

Type of Business: *

Primary Industry *

How did you find us? *

Payment Details

Payment Method

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 Montana Captive Insurance Association, Inc. 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 Montana Captive Insurance Association, Inc., 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

CSC

Billing Street

Billing Zip Code

Total Amount Due

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

Online New Member Application

Membership Dues

Contact Information Contact Information

Additional Information Additional Information

Payment Details Payment Details

Contact Information

Additional Information

Payment Details