Missouri Self-Insurers Association
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MSIA Annual Meeting
MSIA Annual Conference & Exhibition
September 19-21, 2021
Thank you for participating in an MSIA event. Please fill out the form below for the relevant information for this event and
click
the
Submit and Pay
button at the bottom. You will be redirected to Authorize.net for payment for this event. If you have any issues, please let us know at info "at" mo-msia.com.
participation
Registrant Information
Name(s):
Firm/Company Name
Address
City
State
Zip
Email
Phone
Spouse/Companion Name
Please supply the names of additional registrants (other than spouse/guest):
Exhibitor/Sponsor Information
Sponsorship/Exhibit fees are due by September 7, 2021 to guarantee acknowledgement in the printed convention agenda packet.
Gold Sponsor includes:
5-minute presentationto attendees
Signage in Exhibition Area
Name in Convention Program
Gold Ribbon Nametag
Silver Sponsor includes:
Signage in Exhibition Area
Name in Convention Program
Silver Ribbon Nametag
Exhibit Space includes
6ft drapped table
2 chairs for 2 booth attendees
Waste basket
Exhibitor Ribbon Nametag
Please select your participation level(s):
Gold Sponsor | $750
Silver Sponsor | $400
Exhibitor | $450
Exhibitors Only:
List the name(s) of booth attendees. exhibit space is for two booth attendees. If you wish to have more than two people at your booth, there will be an additional fee of $125.00 per person.
Monday night dinner is sold separately. See below for adding additional tickets.
Please note additional booth attendees may be added for a fee of $125.00 per person:
Any number over 2 additional attendee and you will have to pay for the quantity separately. This option will be available on the next page.
Add the names here for any and all additional registrants you will be paying for separately if number exceeds 2.
Additional Attendee
Additional Attendees Names
Does your booth need Solid Wall Behind?:
Yes
No
Does your booth need electrical?
Yes
No
Does your booth need special equipment?
Yes
No
Number of Ticket Reservations for Sunday evening event compliments of MSIA -no fee
Purchase Ticket Reservations for Monday evening event @ $50.00 each.
Any number over 1 additional Monday night event and you will have to pay for the quantity separately. This option will be available on the next page.
1 Monday Ticket Reservation
MSIA Member Registration Fees / Participation
Registration fee covers all scheduled business and social events; including Sunday and Monday evening activities, two breakfasts and the luncheon. To enable us to provide an accurate guarantee (and be fiscally responsible with association money), please indicate below what events you plan to attend.
REGISTER BEFORE AUGUST 19, 2021 FOR THE EARLY REGISTRATION RATE.
Last day for conference registration is SEPTEMBER 9, 2021.
Check the appropriate registration per your membership status:
Note:
Additional registrations from the same member organization (including affiliate and associate members) will be given a discount registration fee.
Early Bird Discount:
August 20th each year.
Before
After
MSIA Regular or Affiliate Member (1st Registrant)
$220.00
$260.00
Additional Regular/Affiliate Registrant
$175.00
$225.00
MSIA Associate Member (1st Registrant)
$265.00
$310.00
Additional Associate Registrant
$215.00
$265.00
Non-Member Registrant
$350.00
$390.00
Spouse/Guest Package
*
$115.00
$165.00
*
(Member or Non-Member) - Allows access to evening events only
Note:
Additional registrations from the same member organization (including affiliate and associate members) will be given a discount registration fee.
Yes, I will attend the Sunday evening event
Yes, I will attend the Monday evening event
Yes, my spouse/guest will attend the same evening events
*
No, I will be unable to attend the evening events
*
Must purchase Spouse/Guest package.
Human Verification
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Please enter characters of the word here in RED with the correct CASE in the Human Verification box.
Please provide a valid zip.
Last 4 Digits of the Card You Are Using
Missouri Self-Insurers Association
Contact Us
101 East High Street, Suite 200
Jefferson City, MO 65102
info@mo-msia.com
573-634-5858
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