IDRA PROFESSIONAL LIABILITY INSURANCE

ENROLLMENT FORM

____________________________________________________

 

First Name:___________________________________ Middle Initial:_________

Last Name:________________________________________________________

Home Address:_____________________________________________________

City:____________________________  State:_________  Zip:_______________

Work Phone: (      )________________  E-Mail:___________________________

Agency:_____________________________ Social Security #:_______________

Payment Mode (check one):  __ Annual;    __ Semi-Annual

Payment Method (check one):  __Check   (Mail payment with Enrollment Form)

 

                                                  __Credit Card (Administrator will contact you upon receipt of Enrollment Form)

 

Are you a current member of IDRA? ____ Yes   ____  No** 

 

**Enrollees must be a Membership Plus member if you reside within 60 miles of Washington, DC.

**Non-Member enrollees residing more than 60 miles from Washington, DC will be charged an Association fee of $4.00 per Semi-Annual bill or $6.00 per Annual bill.

 

                                          Annual      Semi-annual               

Coverage                       Payments        Payments       

 

$1,000,000                    $266.00             $133.00                      

 

I hereby enroll under the IDRA Professional Liability Insurance Policy for which I am eligible.  I also attest that, as of this date, I have no knowledge of any allegation, claim or suit, or any act, error or omission, which might reasonably be expected to result in a claim or suit.

 

 

Signature:_________________________________    Date:__________________

 

 

To enroll, please print this application, complete and mail with payment to:

Mass Benefits Consultants, Inc., P.O. Box 828, Annandale, VA  22003-0828