Join the SCIC

To join the SCIC, please provide us with the following information. An SCIC representative will contact you to discuss your membership.

Firm Information:

Firm Name:
Address:
Address (cont.):
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
ZIP :
Phone:	-   -
Fax:	-   -
Web Site:	Must begin with http:// or https://
Sector(s):	Motor Vehicle Consumer Home
Other sectors:
Entity Type(s):	Administrator Provider Insurer Manufacturer Retailer

Billing Information

Check here if the billing address is the same as the firm address. If not, please complete the billing address information below:

Billing Contact:
Address:
Address (cont.):
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
ZIP:

Primary Contact Information:

First Name:
Last Name:
Title:
E-Mail:

Secondary Contact Information:

First Name:
Last Name:
Title:
E-Mail:

Annual Membership Dues:

Annual membership dues are billed upon joining, but may be paid quarterly upon request.

Bill me:

Annually ($10,000) Quarterly ($2,500)

Comments: