OSIA Member Application Form

OSIA membership is an annual membership that runs from May 1 to April 30 of the following year. There are two categories of membership available:
REGULAR MEMBERS.....Any person, firm or corporation, being a currently certified self-insurer under the provisions of the Oregon Workers' Compensation Law or any large self-assumed program (large-deductible insureds) shall be eligible for membership in this corporation as a Regular Member. Each member organization shall be entitled to one vote on any issue or matter submitted to or required to be submitted to a vote of the membership.
ASSOCIATE MEMBERS....Any person, firm, organization, corporation or other entity specifically in business to provide a service in connection with workers' compensation matters for self-insured employers shall be an Associate Member. Associate Members shall not be entitled to vote or hold office in the corporation except for the office of Associate Member Representative which shall have full voting privileges.

Please fill in all information below then click the submit button:

Select the member category (regular or associate member).

Regular member dues are based on the # of employees in Oregon.

Regular Member with 1-100 employees: Annual Dues $425

Regular Member with 101-1001 employees: Annual Dues $450

Regular Member with 1001-5000 employees: Annual Dues $475

Regular Member with over 5000 employees: Annual Dues $500

Regular members who either self-insure or have a large self-assumed program, indicate below whether you:
Self-Administer

Use a Service Company

Associate Member Annual Dues $425

If you are applying as an Associate Member check the business service category below that you offer:

Attorney

Medical Services

Claims, Insurance, Risk Management

Investigators

Vocational Services

Company:

Contact First Name:

Last Name:

Business Title:

Company street address:

City, State, Zip:

Phone:

Fax:

E-Mail:

Directory Information
List below the names and titles of additional persons in your company who should be listed in the OSIA Membership
Directory (published yearly)

First Additional Name:

Title:

Phone:

Email:

Second Additional Name:

Title:

Phone:

Email:

Third Additional Name:

Title:

Phone:

Email:

Fourth Additional Name:

Title:

Phone:

Email:

Total Amount Due:

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Regular member dues are based on the # of employees in Oregon.
	Regular Member with 1-100 employees: Annual Dues $425
	Regular Member with 101-1001 employees: Annual Dues $450
	Regular Member with 1001-5000 employees: Annual Dues $475
	Regular Member with over 5000 employees: Annual Dues $500
Regular members who either self-insure or have a large self-assumed program, indicate below whether you:
	Self-Administer
	Use a Service Company
	Associate Member Annual Dues $425
If you are applying as an Associate Member check the business service category below that you offer:
	Attorney
	Medical Services
	Claims, Insurance, Risk Management
	Investigators
	Vocational Services

OSIA Member Application Form

Company:

Contact First Name:

Last Name:

Business Title:

Company street address:

City, State, Zip:

Phone:

Fax:

E-Mail:

First Additional Name:

Title:

Phone:

Email:

Second Additional Name:

Title:

Phone:

Email:

Third Additional Name:

Title:

Phone:

Email:

Fourth Additional Name:

Title:

Phone:

Email:

Total Amount Due:

Send mail to osia@osia.com with questions or comments about this web site.