The American Academy of Insurance Medicine

Application for Membership

Last Name	*
First Name	*
Credentials	*
Company Position/Title
Company Name
Division
Company Address	*	City	*
Country	*
State/Prov	*
Zip/Postal Codev	*

Office Telephone	*	Fax
Email	*

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?		Certification

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, who are disabled, age 65 and above and working less than 10 hours per week.

Membership Dues	*
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
	Card Number *
	Cardhold Name *
	Expiry date *



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