ICCIE

International Center for Captive Insurance Education

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ICCIE DESIGNATION PROGRAM

Please submit your information below to apply for the ICCIE Designation Program.

1. Registrant Information

*First Name
MI
*Last Name
*Street Address


*
City

*State / Province

*Zip

Country

*Email

Phone (w)

Phone (h)

Age
Sex: Male Female
*What is your work experience in captive insurance, risk management, or a related field?
Reason for enrolling in the course:
(please indicate all that apply; if more than one, please number, with '1' being the MOST important reason)
Professional Development
Personal Interest
Enhance my value as an employee
Requested by my employer
Other (pls. explain)

2. Sponsor Information

ICCIE requires each student to have a sponsor, which can be a supervisor at work, an educational reference, or other acquaintance who will be recommending the applicant for the program.

*Name

*Address

*
City

*State / Province

*Zip

Relationship to applicant

How long has Sponsor known Applicant?

Might the sponsor be willing to serve as mentor to the applicant?

If not, is there a recommendation of anyone else as the applicant's mentor?

*3. How Did You Hear About Us?

Yes, sign me up for the ICCIE Newsletter