Self Funding Employers Association MEMBERSHIP APPLICATION FORM

Self Funding Employers Association (SFEA)
Please complete this form for submission to Self Funding
Employer Association
Mail: 1128 Royal Palm Beach Blvd., Suite 138
Royal Palm Beach, Florida 33411
Fax to: 866-332-4285

Company / Member's Information Name (First, Last) : *

Company : *

Title / Position : *

Phone : *

Email : *

Verify Email : *

Fax :

Address : *

City : *

State : *

Zip Code : *

Website :

Contact Person's Information

Please enter the main point of reference/contact person that the SFEA should communicate with regarding membership.

Name (First, Last) : *

Title/Position : *

Phone : *

Email : *

Verify Email : *

Select Membership Level

	Government/Country Membership	$25,000
	Corporate Premier	$5,000
	Insurance Company	$2,000
	Corporate Wellness Company	$2,000
	Government Agency	$500
	University/Academic Center	$500
	Health Insurance Agent	$500

Terms & Conditions

By Clicking here I Agree to the Terms & Conditions applied for the Membership of the Self Funding Employers Association (SFEA).

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