Name of Company *

Head Office Address *

Name of CEO *

Tel *

Fax *

Email *

Date of establishment of institution *

Number of Branches *

Number of Staff employed *

Reinsurers you do business with:

Type of Company *
Life onlyLoss or Claims AdjusterNon-Life onlyBrokingCompositeReinsurerActuary

Reinsurers you do business with

Type of membership applied for *
Ordinary (For institutions with headquarters registered in a WAICA country)Associate (For institutions with headquarters registered outside WAICA)Intermediaries:(For institutions with headquarters registered in a WAICA country)

First Name

Last Name

Email *

Position

Date

Attach a copy of your Certificate of Incorporation

Attach a copy of your latest Renewal of Registration