Publication Order Form 718 Providence Rd. • PO Box 3025 • Malvern, PA 19355 Phone: 610.644.2212 • Fax: 610.640.5388 • www.ircweb.org

Date: _______________________

I would like to order the following Insurance Research Council publications.

Subtotal  ____________   

(PA deliveries add 6% - Allegheny and                                                 
Philadelphia County deliveries add 7%)        Tax   ____________   

Total  ____________   

______For Overnight delivery, a $10.00 additional charge will be added to your order total  OR
______Charge Fed Ex Account #_______________________________________________

Please make checks payable to the Insurance Research Council
(payment or purchase order MUST accompany order)

For Charge:         MasterCard         Discover         American Express       VISA

Account Number: ___________________________________________ Expiration Date: _____________

Cardholder’s Signature: ________________________________________________________________

Ship to: ____________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

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Telephone: ___________________________________ Fax: __________________________________

E-mail: ____________________________________________________________________________