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IRC Membership Application Form

Name of Company: _________________________________________________

Street Address: ____________________________________________________

P.O. Box (if any): ___________________________________________________

City/State/ZIP: _____________________________________________________

Designated Representative of Company: _________________________________

Title: _____________________________________________________________

Telephone: ________________________ FAX: ___________________________

E-mail: ___________________________________________________________

Alternate Designated Representative: ____________________________________

Title: _____________________________________________________________

Telephone: ________________________ FAX: ___________________________

E-mail: ___________________________________________________________

Mail To:	Elizabeth A. Sprinkel Senior Vice President Insurance Research Council 718 Providence Rd.  P.O. Box 3025 Malvern, PA  19355-0725
Telephone:	(610) 644-2212
Fax:	(610) 640-5388