TPA - Club Membership Registration Form

Organization Name*
Please tell us the full name of your organization.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Name*

First NameLast Name
Your Title
Your Phone Number
Your E-mail*
Additional Persons to be included on TPA mailing list
Name

First NameLast Name
Title
Email
example@example.com
Name

First NameLast Name
Title
Email
example@example.com
Select Annual Revenue from ID/A Claims (click here for our 2022-23 Dues Policy Statement) [Policy Attached]
Annual Revenue*

Over $4 Million (Current pricing through June 2023, $2,499)$2-4 Million (Current pricing through June 2023, $1,699)Less Than $2 Million (Current pricing through June 2023, $499)
Payment Method*

Enroll in Monthly Payment Plan (includes payment processing fee)Bill Me through June 30, 2023 at the amount indicated above
Privacy Policy
By clicking submit you acknowledge that you agree to our Privacy Policy. Once you submit your application, we will contact you shortly to complete your membership application.

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Additional Persons to be included on TPA mailing list