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RENEWAL FORM AND ANNUAL FEES

• Please review the membership categories, which have been changed. 
• You may now qualify under a different category with a different fee.
• There is no longer a category for “Part time” work of less than 4 hours a week

CATEGORIES OF MEMBERSHIP:
Active: meaning physicians who are Medical Directors, Associate or Assistant Medical Directors, or Medical Consultants of insurance companies, or other physicians with equivalent duties; may vote and hold office
 Fee $200

Associate: meaning physicians who are not Medical Directors, Associate or Assistant Medical Directors or Medical Consultants of insurance companies but who have a professional interest in insurance medicine; may not vote or hold office           Fee $100

Emeritus: being those who have retired from active medicine but who wish to stay in touch and to access the Proceedings of the annual meeting.        Fee $35

**Dues are payable in full by December 31 of each year**

NAME: ____________________________________________________________________

COMPANY NAME: __________________________________________________________

ADDRESS: _________________________________________________________________

                    __________________________________________________________________

BUSINESS PHONE: __________________________________________________________

BUSINESS FAX: _____________________________________________________________

EMAIL ADDRESS: ___________________________________________________________

Category of Membership _____________________________ and fee enclosed $ __________
(If you are changing your category of membership, please briefly explain why _____________
____________________________________________________________________________
____________________________________________________________________________

Are you a member of the Canadian Medical Association?                        Yes _____No _____
Are you a member of the American Academy of Insurance Medicine?    Yes ____  No _____
Are you planning to attend next year’s Annual Scientific Meeting?          Yes ____  No ____

TO MAINTAIN YOUR STATUS IN CLIMOA, PLEASE RETURN THIS FORM WITH YOUR CHEQUE FOR THE APPROPRIATE FEE FOR YOUR CATEGORY OF MEMBERSHIP TO:
CLIMOA Secretary
C/O Unconventional Planning,
32 Colonnade Road, Unit 100
Ottawa, ON& K2E 7J6