Membership Application 

Type of Membership: Corporate Membership ($150) 2nd - 10th Corporate Membership ($90) Individual Membership ($125)
Applicant Name:
Professional Designation:
Title:
Business Name:
Type of Business: Insurance Company TPA Medical Management Vocational Rehab Firm Employer Independent Investigation Firm Law Firm Risk Management Firm Medical Provider
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Meeting Notice Preference: Bloomington Chicago Collinsville All
How did you learn about WCCA: Meeting Guest Brochure Referred by Member Other
Willing to Serve on committee: Interested Not interested at this time

After submitting the application, you may pay online. Thank you for your interest in the WCCA!