Membership Application

Thank you for your interest in joining the Oregon Self-Insurers Association. Please fill out the contact information in the application form below. The first name entered in the form will be designated as the primary contact for OSIA. Additional names can be entered at the bottom of the form. After the form is submitted OSIA will send you an invoice for membership dues. If you prefer to pay your dues with a credit card (Visa or MasterCard) please call Cory Cross at the OSIA office (503-873-0985).

Name

Phone

Company

Address Line 1

Address Line 2

City, State, Zip

Select a membership type. There are two categories of membership available:

Self Insured Employer
Any person, firm or corporation being a certified self-insurer under the provisions of the Oregon Workers' Compensation Law or any large self-assumed program. Annual dues are $425.
Associate Member
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. Annual dues are $425.

Membership Type

Enter the name and email of additional employees who should receive information and notices from OSIA.

Additional Name

Additional Email

Additional Name

Additional Email

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