Membership

Dear Indiana Self-insurer and Self-insurance professional:

It is time to renew your ISIA membership for 2019. ISIA is the only organization in Indiana dedicated to serving Indiana employers and claims professionals who self-insure and administer worker’s compensation self-insurance obligations. ISIA works for its members and with other employer groups and the Indiana Worker’s Compensation Board to make sure that the Indiana Worker’s Compensation Act remains responsive and effective.

Please review our HOME page at www.indianaselfinsurers.org for a description of ISIA and its goals and please renew your ISIA membership today.

Sincerely,
INDIANA SELF-INSURERS ASSOCIATION, INC.
Robert Fanning, Executive Director

2019 NEW MEMBER AND RENEWAL APPLICATION

The Indiana Self-Insurers Association, Inc. is a nonprofit association of Indiana employers which self-insure their worker’s compensation obligation (Corporate Membership) and of companies which provide services to self- insured employers (Associate Member).

ANNUAL DUES FOR CORPORATE MEMBERS are based on the number of Indiana employees:

Fewer than 500	$350.00
500 but fewer than 2,000	$425.00
2,000 but fewer than 5,000	$475.00
5,000 but fewer than 10,000	$525.00
10,000 or more	$700.00
ANNUAL DUES FOR ASSOCIATE MEMBERS are: $350.00

Click Here To Download the Form Fillable PDF of the Application.

2019 New Member and Renewal Online Application

Corporate or Associate Member*
- Corporate Member
- Associate Member
Corporate Membership: Employers which self-insure their worker’s compensation obligation. Associate Member: Companies which provide services to self-insured employers.
Company Name*
Company Main Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Representative Name*
First Last
Representative Email*
Representative Phone*
Fax Number
Second Representative Name
First Last
Second Representative Email
Third Representative Name
First Last
Third Representative Email
Other Notes.

Please make check payable to:

“Indiana Self-Insurers Association, Inc.” (IRS #35-1420875)

Mail Check & Application to:

Robert Fanning, Executive Director
P.O. Box 160
Syracuse, IN 46567

Remember you can just Download the Form Fillable PDF of the Membership Form and mail it in.

Officers

President:

Jerry Williams
Indiana University Health.
340 West 10^th Street
Indianapolis, IN 46202
Phone: (317) 963-7869
Fax: (317) 963-7848
E-mail: [email protected]

Secretary/Treasurer:

Jessica Amos
Mittal Steel USA
3210 Watling Street
East Chicago, IN 46312
Phone: (219) 399-5180
FAX: (219) 399-5814
E-mail: [email protected]

DIRECTORS

Jessica Amos
Mittal Steel USA
3210 Watling Street
East Chicago, IN 46312
Phone: (219) 399-5180
FAX: (219) 399-5814
E-mail: [email protected]

Sandy Fralich
Indy Steel Erectors
c/o JWF Specialty Company
600 E. 96th Street
Suite 425
Indianapolis, IN 46240
Phone: (317) 706-9500
E-mail: [email protected]

Gary Gonthier
General Motors Company
300 Galleria Office Center, Suite 200
Southfield, MI 48034
Phone: (248) 223-6592
E-mail: [email protected]

Michael Hough
Nishikawa Cooper, LLC
324 Morrow Street
Topeka, IN 46571
Phone: 260-593-2156
Fax: 260-593-2037
E-mail: [email protected]

Jerry Williams
Indiana University Health
340 West 10^th Street
Indianapolis, IN 46202
Phone: (317) 963-7869
Fax: (317) 963-7848
E-mail: [email protected]

EXECUTIVE DIRECTOR

Robert Fanning
DUE DOYLE FANNING LLP
8440 Allison Point Blvd., Suite 350,
Indianapolis, IN 46250
Phone: (574) 457-7600
FAX: (574) 457-0189
E-mail: [email protected]

Indiana Self Insurers Association, Inc.