Application for Membership of IMIA NOTE: Before you fill in this form, please be aware of the Constitution of IMIA, the Fees payable by members and the Roles and Opportunities of Members. * Name of organisation * Address of head office * Website address * Grade of membership being applied for (National Association, Reinsurer, Insurer, Associate (e.g. Loss Adjuster, Broker, Lawyer, Expert) * Number of employees /members in your organisation approximately * Number of senior employees/individuals involved in engineering insurance * Locations of offices involved in engineering insurance (countries if applicable) * Please explain how you consider your organisation would contribute to IMIA's goals If your application is successful who will be the main contact? * Name * Job title/Qualifications * Address * e-mail address * Telephone number * If your application is successful, does your organisation agree to abide by IMIA's constitution Yes No * If your application is successful do you intend to send a delegate to IMIA's annual conferences? Yes No