Application for Membership

Last Name *
First Name *
Credentials *
Company Position/Title
Company Name
Division
Company Address * City *
Country *
State/Prov
*
Zip/Postal Code *
   
Office Telephone * Fax
Email *    
       
Home Address * City *
Country * Zip/Postal Code *
State/Prov. *    
Home Telephone    
Preferred Mailings Office Home *    
       
Medical School Year of Graduation
What, if any is your field of specialization?    
       
Member of AMA: Yes No *    
BIM Certified Yes No *    
       

Categories of Membership:

Active membership shall consist of physicians (MD or DO) who are medical directors, associate medical directors, assistant medical directors, or medical consultants for insurance companies. Active members shall be entitled to hold office, vote, serve on committees, make nominations and generally exercise the rights of full membership.

Associate membership shall consist of physicians (MD or DO) who are not medical directors, associate medical directors, assistant medical directors, or medical consultants of insurance companies, and nurses or other health professionals who serve in the capacity of insurance company medical directors, associate medical directors, assistant medical directors or medical consultants. They may not hold office or vote, but may be appointed to committees.

Affiliate membership shall consist of individuals who have a professional interest in insurance medicine such as paraprofessionals, underwriters, and actuaries. They may not hold office or vote, but may be appointed to committees.

Emeritus membership shall consist of former dues paying members, retired or working less than 10 hours per week as an employee or consultant for a salary or fee in the field of Insurance Medicine. He/She may not hold office or vote, but may be appointed to committees.

       
Payment Details  
   
Membership Due *
   
Payment Method Check (Please make check out to the American Academy of Insurance Medicine. Check must be drawn on a US bank or be an international money order)
  Credit Card (please note additional 2% fee will be charged)
       
 
You can also apply by mail or fax. Download the form.
   
By Mail:
American Academy of Insurance Medicine
100-32 Colonnade Road
Ottawa, ON
Canada
K2E 7J6
By Fax:
(613) 721-3581
Credit card payments only
 
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