(To download this form in PDF format click here)

If your organization would like to join Americans for Insurance Reform, please fill
out the form below and fax or mail it to:
FAX: 212/764-4298, Attention: Daniel Albanese
or Mail: Americans for Insurance Reform; Attention: Daniel Albanese; 90 Broad St.,
Suite 401; New York, NY 10004

____________________________________________

(Organization name)

endorses and supports the mission of Americans for Insurance Reform to reform the insurance industry and authorizes Americans for Insurance Reform to mention this endorsement in connection with its activities. Americans for Insurance Reform agrees to keep the above-mentioned organization informed of its activities.

______________________________________________________________

(Signature) (Title) (Date)

Name ___________________________________________________________

Title ____________________________________________________________

Organization _____________________________________________________

Address _________________________________________________________

________________________________________________________________

Phone ________________ Fax ________________ E-mail _________________

__ We want to learn more about AIR and how we can become more involved. Let us know how we can support grassroots AIR activities in our area.

___ We would like to be kept informed about federal legislation and would consider signing onto letters to lawmakers in support of or opposition to specific legislation. We understand that our name will not be used on any lobbying materials without prior review and consent.

Optional: If yours is a membership organization, how many members do you have? _______

PLEASE FAX THIS SHEET TO Daniel Albanese AT: 212/764-4298 or mail to: Americans for Insurance Reform; Attention: Daniel Albanese; 90 Broad St., Suite 401; New York, NY 10004.