Meeting Information – Pacific Claim Executives Association

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First Name*

Last Name*

Company*

Company Address 1*

Company Address 2

Company City*

Company State*

Company Zip*

Day Phone*

Fax #

Email*

Are you an Insurance Company*

If yes, is it part of a group

Type of Division

Date Company Organized

Major Lines Written

Written Premium Volume in the Pacific States

Company's Most Recent Best's Rating

Size of Company (revenue, # of claims, etc)

Representative's Title*

For the year

Years with Company*

Years in present capacity*

Is representative the top claim executive in Pacific States?*

If no, please explain

Representative Reports To (name & title)

Do you have authorization to represent the Company on PCEA matters?*

*Required field