International Center for Captive Insurance Education



If you are registering for an individual course or teleconference only, please fill in the following information:

1. Registrant Information

*First Name
*Last Name
*Street Address


*State / Province




Phone (w)

Phone (h)
*What is your work experience in captive insurance, risk management, or a related field?

*2. Purchasing Information

Date of course/teleconference

Course or teleconference name

Face-to-face Online format Teleconference
Course fee (see schedule below)
Elective: Accounting for Captives: Financial Reporting and Analysis: $900.00
Elective: Accounting for Captives: Interpretation and Management Perspectives: $900.00
Elective: Captive Board Governance: $750.00
Elective: Captive Claims Management Best Practices and Reinsurance: $750.00
Elective: Employee Benefits and Captives: $750.00
Elective: Healthcare Captives Overview: $750.00
Elective: Investments and Captives: $975.00
Elective: Risk Retention Groups: $750.00
Elective: Understanding the Intricacies of Cell Captives: $900.00
An Introduction to Alternative Risk Financing Mechanisms: $750.00
Understanding Risk and Risk Retention Mechanisms: $1050.00
Forming and Operating a Captive: $1050.00
Business Ethics in the Captive Industry: $750.00
Reinsurance and Other Risk Transfer Mechanisms: $750.00
Predicting Risk and an Introduction to Actuarial Science: $750.00
Any Teleconference: $135 ($100 for organizations sponsoring ICCIE students)

3. Billing Address (if different than above)

Street Address


State / Province


*4. Payment Information

Check American Express
Mastercard Visa
Credit card number
If paying by check:
  1. Print and fill out this form
  2. Mail this form and your check to:

    2517 Shelburne Road, Suite 2
    Shelburne, Vermont 05482

5. Enrollment Information

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
Certification in captive insurance
Designation maintenance requirement

Please Note: a student's space in the course cannot be saved until payment has been received by ICCIE.

View additional information about ICCIE's payment/refund policies.

*6. How Did You Hear About Us?

7. Submit Your Information

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