SPeaKer - SIIA

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Registrationinformation Prior to June 24, 2011 After June 24, 2011 Employer/Self-Insured Entity SIIA Member $295 $350 SIIA Member Additional $250 $295 Non-Member $450 $495 Industry Service Provider SIIA Member $850 $995 SIIA Member Additional $695 $750 Non-Member $1,295 $1,395 *For groups of 6 or more please contact SIIA Headquarters for discounted group pricing information at 800.851.7789. EMPLOYER/SELF-INSURED ENTITY Self-Insured Entity is defined as an organization that is self-insured for group health care and/or workers’ compensation, or is a captive insurance company/risk retention group. This also includes employers considering self-insurance/captive insurance. Selfinsurance industry service providers including but not limited to, TPAs, MGUs, & captive management companies do not qualify for this registration rate even if their organization is self-insured. Registrations submitted by service providers selecting the employer rate will not be processed. INDUSTRY SERVICE PROVIDER Industry service provider is defined as any organization that provides a product or service to the self-insured, fully insured or alternative risk transfer marketplace. This includes, but is not limited to TPAs, MGUs, and captive management companies. MEMBER ADDITIONAL Member additional rates are available to the second and any subsequent registrations from the same member organization. MEMBERSHIP & REGISTRATION FEES SIIA memberships belong to the company, not the individual and are listed in the name of said company. Membership rights and privileges do not extend to subsidiary companies. Special affiliate memberships are available. Call SIIA Headquarters for details at 800.851.7789. 800.851.7789 | www.siia.org HOST HOTEL INFORMATION JW Marriott Desert Ridge Resort & Spa 5350 E. Marriott Drive Phoenix, AZ 85054 Phone: 800.835.6206 www.jwdesertridgeresort.com Note: Only full conference registrants are eligible to reserve rooms at the host hotel. OVERFLOW HOTEL INFORMATION Xona Resort Suites 7677 E. Princess Blvd. Scottsdale, AZ 85255 Phone: 888.222.1059 www.xonaresort.com Hotel reservations at the host hotel and the overflow hotel must be made through SIIA. Accommodations will be made on a first come, first serve basis, based on availability. Hotel reservations will only be confirmed for paid conference registrants. You will receive hotel confirmations directly from the hotel. REGISTRATION CONFIRMATION Conference registration will be sent via email from SIIA Headquarters within two weeks of receipt of your form. SPECIAL SERVICE CLAUSE If you require special accommodations to fully participate, please attach a written description of your needs to your registration form.
Registrant Information To register, please type or print all information requested below. For multiple registrations, please photocopy this form. A separate form must be completed for each conference registrant. Full Name____________________________________________ First Name for Badge____________________________________ Title_________________________________________________ Company _ ___________________________________________ Address_ _____________________________________________ City ______________________ State_____ Zip______________ Phone _____________________ Fax_______________________ E-mail________________________________________________ Is this your first SIIA National Conference? ❑ Yes ❑ No Registration Payment Information Please select registration level: (fee schedule on previous page) ❑ Employer/Self-Insured Entity (Do not select this option unless your company fits the definition provided on previous page) Industry Service Provider Total amount due $____________________________________ Enclosed is my check made payable to SIIA in US funds in the amount of $_ _______________________________________ ❑ Please charge the following: ❑ VISA ❑ MC ❑ Amex ❑ Discover Credit Card Number____________________________________ Name on Card ________________________________________ Billing Address_ ________________________________________ City ______________________ State_____ Zip______________ VAL Code_____________________________________________ (MC, Visa, Discover—last 3 digits on card back; AMEX—4 digits on card front) Signature____________________________ Exp Date ____ /____ 3 Easy Ways to Register 1. Fax your registration to: 864-962-2483 2. Mail your registration to: SIIA, P.O. Box 1237 Simpsonville, SC 29681 3. Online www.siia.org ❑ ❑ Hotel Reservation No Yes Will you need hotel reservations? (If yes, continue below) Hotel reservations can only be made by completing this form. Only FULL conference registrants may secure hotel reservations at the host hotel. All other conference registrants will be placed at the overflow hotel, at the room type/rate available at that time. Accommodations will be made on a first come, first served basis. ❑ JW Marriott Desert Ridge Resort* - $269 + 13.27% tax = $304.70 *Full conference registrations only. ❑ Xona Resort - King Suite - $219 + 13.27% tax = $248.06 ❑ Xona Resort - 2 Bedroom Suite - $350 + 13.27% tax = $396.45 ❑ Xona Resort - Traditional - $199 + 13.27% tax = $225.41 Please check appropriate box below for type of accommodations required: ❑ King ❑ ❑ Double/Double (Hotels are non-smoking) Rooms reserved after September 13, 2011 will be made on a space and rate availability only. Arrival Date___________________________________________ Departure Date_________________________________________ Marriott Rewards #_____________________________________ Guarantee Hotel Reservation Payment for one night’s lodging is required to secure hotel reservations. Hotel Reservations will be made based on availability. ❑ Enclosed is my check payable to my chosen hotel for one night’s lodging. Please send the check to SIIA with this registration form. ❑ Please charge the same account number in the payment information section. ❑ Charge a different account: ❑ ❑ VISA ❑ ❑ MC ❑ ❑ Amex ❑ ❑ Discover Credit Card Number____________________________________ Name on Card________________________________________ Billing Address _____________________________________ City ______________________ State_____ Zip______________ VAL Code_____________________________________________ (MC, Visa, Discover—last 3 digits on card back; AMEX—4 digits on card front) Signature____________________________ Exp Date ____ /____ IMPORTANT: You will receive confirmation of your conference registration via e-mail from SIIA Headquarters within two weeks from receipt of your form. If you do not receive registration confirmation within two weeks, please contact Michiale Machado at 800.851.7789. You will receive confirmation of your hotel reservations via e-mail directly from your chosen hotel. Once confirmation has been received from the hotel, please contact the hotel directly regarding reservation cancellations or changes. One night’s lodging and tax will be charged to the credit card provided upon receipt of registration. To avoid charges, cancellations for accommodations must be received by the hotel 48 hours prior to arrival date. Cancellation Policy: Written cancellations postmarked or faxed on or before September 9, 2011 will receive a refund of 50% of the registration fee. Due to hotel and staffing commitments, all cancellations postmarked or faxed after September 9, 2011, are non-refundable and cannot be transferred to other SIIA functions; however, substitutions are permitted.
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