Texas Association of Manufacturer - Workers' Comp Safety Group

MEMBERSHIP FORM

POLICYHOLDER'S INFORMATION:

COMPANY:
ADDRESS:
CITY/STATE/ZIP:
TELEPHONE: FAX:
WEBSITE:

CONTACT TO RECEIVE ANNUAL RENEWAL INVOICES:

NAME: E-MAIL:

CONTACT TO RECEIVE WORKPLACE SAFETY UPDATES & RESOURCES:

NAME: E-MAIL:

ANNUAL DUES: $100.00*

MEMBERSHIP CATEGORY:

MANUFACTURER MANUFACTURER SUPPLIER MANUFACTURER SERVICE OTHER

INSURANCE AGENT'S INFORMATION:

NAME OF AGENCY:
NAME OF AGENT:
E-MAIL ADDRESS:
ADDRESS:
CITY/STATE/ZIP:
TELEPHONE: FAX:
AGENCY'S WEBSITE:
TEXAS MUTUAL UNDERWRITER'S NAME (IF KNOWN):
*NOTE: THIS FORM IS PROVIDED FOR YOUR CONVENIENCE, BUT YOUR RESPONSES WILL NOT BE SAVED OR TRANSMITTED.
PLEASE PRINT AND MAIL THE COMPLETED APPLICATION AND $100 DUES CHECK TO:
(PAYABLE TO "TEXAS ASSOCIATION OF MANUFACTURERS")
PO BOX 50565
AUSTIN, TX 78763

Notice: Contributions or dues to the Texas Association of Manufacturers (TAM) are not tax-deductible as charitable contributions. However, they may be deductible as ordinary and necessary business expenses. A portion of these dues are not deductible as an ordinary and necessary business expense to the extent that TAM engages in lobbying activities. The nondeductible portion of dues beginning with the year 2006 is 80%.

Please contact Stacy Looney at 512.906.2000 or Stacy.Looney@TAMWorkersComp.com with questions regarding this application.