1. Registrant Information
*Role in Industry
*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)
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.
*State / Province
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
*3. How Did You Hear About Us?