Last
Name
First
Name
Middle
Initial
Company/Firm
Company/Firm
Address
City
State
Zip
Telephone
Fax
Email
Residence
City
State
Zip
Date
of Birth (mm/dd/yyyy)
Place
of Birth (City, State)
College
Degree
Law
School
Degree
Honorary
Society Memberships College/Law School
Admitted
to the Bar in the State of
Year
Admitted to the Bar (yyyy)
List
names of and year of admission of all courts of last resorts, including
United States Court of Appeals, in which you are admitted to practice.
If none, so state
List
all bar associations and all other professional organizations to which
you belong
Name
of Proposer (Note: The proposer and seconder shall serve as references
for defense activity and must be members of IDCA.)
Address
of Proposer
Name
of Seconder
Address
of Seconder
Are
you in private practice?
If
yes, number of years
If
at locations other than above, please state addresses
If
a member or associate of a law firm, so state. Give name of firm and
number of years you have been associated with said firm
Number
of lawyers in your company/firm
Number
of lawyers in your company/firm belonging to IDCA
List
names of your firm members who are IDCA members
If
you have been associated with other firms, give their names, addresses,
and dates of your association
Are
you devoting a substantial portion of your professional time to the
defense of insurance companies, associations, corporations, businesses,
governmental entitles or individuals? If so, state percentage of your
time devoted
State
number of years preceding this application that you have continuously
devoted a substantial portion of your professional time to the defense
of insurance companies, associations, corporations, businesses, governmental
entitles or individuals
Describe
you practice in the five years preceding this application
If
you are a full time employee of an insurance company, association,
corporation, governmental entity or professional organization, give
name and address of company, your title or position, and the number
of years employed
If
you have been employed less than five years, state the name and addresses
of employment preceding this application
Have
you ever been a member of this Association?
Have
you ever applied for membership in this Association?
If
elected to membership, I agree to be bound by the Articles and By-laws
of this Association
First Member in your Firm/Company $200.00