I. Company Information Please use the space below to provide the requested information about the company applying for membership. Organization Name Your Name Mailing Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Phone Fax Email II. Membership Category Please use the space below to select category into which the above company best fits. Membership Type Consultant Insurance Company Claims Company Associate Check all that apply. Involvement Please describe your company's involvement in structured settlements. III. Company Affiliation Please list the names of any parent company, affiliates, subsidiaries or other company related to the applicant company that is involved in the structured settlement business and indicate their involvement in structured settlements. Corporate Parent Name Structured settlement activity NSSTA Member Yes No Subsidiary Name Structured settlement activity NSSTA Member Yes No Other Affiliate Name Structured settlement activity NSSTA Member Yes No IV. Agreement I understand that the NSSTA Membership Committee and the NSSTA Membership Board of Directors must favorably consider this application prior to acceptance. By signature hereto, I declare that the facts herein are true and complete to the best of my knowledge. I also state that my organization, voting and professional members are actively involved in, associated with, or have an interest in the furtherance of periodic payment of compensation on account of personal physical injuries as set forth in Article II of the NSSTA Bylaws. Name Title By clicking "Submit," you agree to the above statement.