Missouri Self-Insurers Association
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MSIA Annual Meeting
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.
Event Information
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 20, 2021 FOR THE EARLY REGISTRATION RATE.
Last day for conference registration is SEPTEMBER 10, 2021.
Type or print name exactly as you wish it to appear on your conference badge.
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):
Human Verification:
Please enter characters from graphic.
Exhibitor Information
Please select your participation level(s):
Gold Sponsor | $750
Silver Sponsor | $400
Exhibitor | $450
Exhibitors Only:
List the name(s) of booth attendees -
two are included in Exhibitor Fee.
Please note additional booth attendees may be added for a fee of $125.00 per person:
1 Additional Attendee
2 Additional Attendees
3 Additional Attendees
4 Additional Attendees
5 Additional Attendees
6 Additional Attendees
7 Additional Attendees
8 Additional Attendees
9 Additional Attendees
10 Additional Attendees
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.
1 Monday Ticket Reservation
2 Monday Ticket Reservations
3 Monday Ticket Reservations
4 Monday Ticket Reservations
5 Monday Ticket Reservations
6 Monday Ticket Reservations
7 Monday Ticket Reservations
8 Monday Ticket Reservations
9 Monday Ticket Reservations
10 Monday Ticket Reservations
Registration Fees / Participation
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.
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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