Deputy Update Application - RIMS

2012 Application for Deputy MembershipHow did you hear about RIMS? __________________________________________________________________________________PRIMARY Reason for joining (Please Choose One)o Networking Opportunities/Chapters o Professional Development/Education o Risk Management Tools and Resources o Government Affairs/AdvocacyAbout your organization (please print)KNOW RISK?KNOW RIMS.Join Today • www.RIMS.org/JoinTodayName of organization requesting membership in RIMS ____________________________________________________________________________________Organization’s Web site ________________________________________________________________________________ Stock Ticker Symbol ____________Are you replacing an existing representative for the member company? o Yes o NoIf yes, who? _____________________________________________________________________________________________________Reason for removal ________________________________________________________________________________________________Are you a new representative for the member company? o Yes o NoProvide a three to five word description of your organization’s primary function, i.e., primary care hospital, commercial bank, clothing retailer, etc. ________________________________________________________________________________________________________________________________________________Provide your company’s primary and secondary four-digit SIC (Standard Industry Classification) code __________________________ _________________________o Mr. o Ms. o Mrs. o Dr. o Other ________________________First Name __________________________ MI _______ Last Name___________________________________Nickname ______________________________Job Title ____________________________________________________________________________ o Male o Female Year of Birth |__|__|__|__|Business/Primary Mailing Address ____________________________________________________________________________________________________City __________________________________ State/Province ________ Zip/Postal Code __________________ Country _______________________________Telephone ____________________________________ Extension _______________ Fax _____________________________________________________Cell Phone ____________________________________E-Mail Address (application will not be processed without e-mail address)_______________________________________________________________________Permanent/Home Address __________________________________________________________________________________________________________City __________________________________ State/Province ________ Zip/Postal Code __________________ Country _______________________________Personal E-Mail Address____________________________________________________________________________________________________________Are you a salaried employee of the organization requesting membership? o Yes o NoDo you obtain your compensation directly from an organization other than the organization requesting membership? o Yes o NoDo you have internal risk management responsibilities for your organization? o Yes o NoWhich of the following functions are you engaged in? (Check all that apply)Property/Casualtyo Alt. Risk Transfer o Claims Management o Insurance Purchase o Risk Control o Self InsuranceOthero Captives o Disaster Planning/Business Continuity o Enterprise Risk Management o Environmentalo Financial Risk Management o Governance/Compliance o Health/Wellness o HR/Benefitso IT Risk Management o Legal o Liability o Operational Risk Managemento Risk Assessment o Safety o Security o Strategic Risk Managemento Supply Chaino Workers’ CompensationDo you sell/manage products or services to risk managers or perform services/consulting for risk management clients? (Includes underwriting, selling, brokering,regulating or rating of insurance; actuarial, risk management or employee benefits-related services, risk management consulting; investigation or settlement of losses,providing legal services; or personnel recruitment). o Yes o No (If you have answered Yes, please complete Associate of the Society application.)Would you like to be included in RIMS online Member Directory? (e-mail address not shown) o Yes o NoIf No, may we release your contact information to other RIMS members upon request? o Yes o NoOccasionally, RIMS may make your postal and/or email address available to screened third party organizations offering products or services that may interest you. Yourcontact information is never released directly to these organizations.Would you like to receive third party information via postal and/or email? o Yes o Noo I would like to be contacted about volunteer opportunities.CHAPTER AFFILIATIONAll RIMS Members are required to belong to a local chapter and pay any applicable local chapter dues. What is your Chapter Preference? (see page 3)Chapter Preference _______________________________________________________________________________ Chapter # |__|__|__|__|1

2012 Application for Deputy MembershipJoin Today • www.RIMS.org/JoinTodayMembership InformationOrganizations that have employees with internal risk management responsibilities are eligible to be Corporate members. Two employees with risk managementresponsibilities are included in Corporate dues. Additional Corporate member representatives (subject to approval) may be added at an annual cost of $170 U.S. perperson, plus applicable local chapter dues. Complete a Corporate Member second representative section for each additional representative. Corporate membershipis held by the organization, not by the individual Deputy.Membership DuesAdditional Corporate Membership Dues - $170 U.S.Chapter Dues* $ _____________ U.S.Total $_____________________ U.S.Membership Dues are not refundable and are not prorated.*Chapter dues not included with this application will be billed directly to your credit card or invoiced by RIMS or the Chapter. Please refer to page 3 of this application forchapter dues listing. The most up-to-date pricing can be found on www.RIMS.org/JoinToday. Membership applications are processed upon receipt of full payment of allmembership dues. You will receive an e-mail notification of your active membership after your application is processed and approved. Please allow up to 2 weeks for processing.U.S. Taxpayers: RIMS dues are not deductible as a charitable contribution for tax purposes but may be deductible as a business expense. 16.5% of 2012 Society Dues arenot deductible due to lobbying. Members will be advised each year of the non-deductible portion of the Society dues on their renewal invoice.RIMS Federal Tax ID# 13-1860397. If you need a W9 tax form, it is available at www.RIMS.org/W9.Payment Method and InformationPayment for membership dues may be made by check, Visa, MasterCard, American Express and Bank Transfers. Please remit payment in U.S. dollars, drawn on a U.S.bank, payable to Risk and Insurance Management Society, Inc.For check or money order payments via regular mail:Risk and Insurance Management Society, Inc., P.O. Box 95000-2345, Philadelphia, PA 19195-2345For bank transfers:*TD Bank, 469 Seventh Avenue, New York, NY 10018Account name: RIMS Operating AccountAccount number: 7920319089ABA number: 026013673Swift number: NRTHUS33* Bank Transfers must include the applicant’s name(s) and company. For accurate processing enclose a copy of your bank order with yourmembership application. Applicant is responsible for all bank charges. Please add an additional $30 U.S. for bank transfers administrative fee.For credit card payments:You may fax the completed application with your credit card payment to 212-655-7430 or email to membership@RIMS.org.If you prefer to mail your application, use the following address:Risk and Insurance Management Society, Inc.RIMS USE ONLYAttention: Membership Dept.1065 Avenue of the Americas - 13th FloorNew York, NY 10018-2506Please bill my credit card: o American Express o Visa o MasterCardCard No. _______________________________________________Exp. Date________________________________Print Name as it appears on card ____________________________________________________________________Signature _____________________________________________________________________________________MEMBERSHIP PLEDGEI verify that the information herein is true and accurate, and that I have read Article IV – Membership, Section 1 of RIMS Constitution and Bylaws on page 5 and herebycertify that our organization is eligible for membership in the Risk and Insurance Management Society, Inc. I further affirm that our organization will subscribe to theobjectives of RIMS and abide by RIMS Constitution and Bylaws and any amendments thereto (located at www.RIMS.org/bylaws).Name of Organization ______________________________________________________________________________________________Signature of Primary Representative ___________________________________________________________ Date ____________________I understand that by providing my mailing address, e-mail address, telephone number and fax number, I consent to receive communications sent by or on behalf of RIMSvia these media. I also understand that RIMS will not share my e-mail address with other organizations.The Membership Dues are printed on this form. Chapter dues vary from chapter to chapter. The most up to date pricing can be found on www.RIMS.org.Membership or Chapter dues not included with this application or renewal will be billed directly to your credit card or invoiced by RIMS or the Chapter.Membership will not be processed until full payment is received. Please call 212.655.6220 for questions regarding total amount due.2

Chapter ListingAll dues are per individual and are shown in US dollars.Join Today • www.RIMS.org/JoinTodayUNITED STATESALABAMA001 Alabama (Birmingham) $100ALASKA074 Alaska (Anchorage) $75ARIZONA049 Arizona Central (Phoenix) $100CALIFORNIA028 Golden Gate (San Francisco) $70033 Los Angeles $50052 Orange County (Orange) $50088 Sacramento Valley $25045 San Diego $25073 Silicon Valley $100COLORADO018 Rocky Mountain (Denver) $75CONNECTICUT012 Connecticut Valley (Hartford County) $25044 Fairfield/Westchester (Greenwich) $25DELAWARE014 Delaware Valley/Philadelphia $65DISTRICT OF COLUMBIA070 Potomac (Washington, D.C.) $50FLORIDA016 Broward (Fort Lauderdale) $30085 Central Florida (Orlando) $20093 Greater Miami $50065 Northeast Florida (Jacksonville) $80089 Palm Beach $50090 Southwest Florida (Naples) Chapter Collects048 Tampa Bay $50GEORGIA003 Atlanta $50HAWAII019 Hawaii (Honolulu) $15ILLINOIS009 Chicago $50083 Mid-Illinois (Peoria/Bloomington) $50INDIANA042 Indiana (Indianapolis) $200IOWA086 Greater Quad Cities (Muscatine) $50060 Iowa (Des Moines) $35KANSAS017 Greater Kansas City $35KENTUCKY053 Kentuckiana/Bluegrass $45LOUISIANA034 South Louisiana (New Orleans) $50MARYLAND008 Chesapeake (Baltimore) $50070 Potomac (Washington, D.C.) $50MASSACHUSETTS022 Massachusetts (Boston) $75MICHIGAN015 Detroit $50054 Western Michigan (Grand Rapids) $25MINNESOTA024 Minnesota (Minneapolis) $50MISSOURI017 Greater Kansas City $35084 Ozarks Area (Springfield) $15032 St. Louis $75NEBRASKA043 Great Plains (Omaha) $50NEVADA081 Nevada (Las Vegas) $75105 Northern Nevada $25NEW JERSEY026 New Jersey (Somerset) $75014 Delaware Valley (Philadelphia) $65NEW YORK101 Long Island (Woodbury) $100027 New York (New York City) $75036 Upstate New York (Rochester) $50NORTH CAROLINA005 Carolinas (Charlotte) $75047 Piedmont (Raleigh-Durham) $30OHIO007 Central Ohio (Columbus) $50010 Ohio River Valley (Cincinnati) $75011 Northeast Ohio (Cleveland) $50087 Toledo $50OKLAHOMA072 Central Oklahoma (Oklahoma City) $100029 Eastern Oklahoma (Tulsa) $80OREGON030 Oregon (Portland) $40PENNSYLVANIA058 Central Penn (Harrisburg) Chapter Collects014 Delaware Valley (Philadelphia) $65031 Pittsburgh $40SOUTH CAROLINA076 Palmetto (Columbia) $50071 Western Carolina (Greenville) $15TENNESSEE059 Cumberland (Nashville) $50023 Memphis $110TEXAS080 Central Texas (Austin) $65013 Dallas-Fort Worth $60020 Houston $55056 South Texas (San Antonio) $50UTAH069 Utah (Salt Lake City) $50VIRGINIA070 Potomac (Washington, D.C.) $50037 Virginia (Williamsburg) $75WASHINGTON038 Washington (Seattle) $35WISCONSIN039 Wisconsin (Milwaukee) $50CANADA (in U.S.$ equivalent)ALBERTA061 Northern Alberta (Edmonton) Chapter Collects002 Southern Alberta (Calgary) Chapter CollectsBRITISH COLUMBIA004 British Columbia (Vancouver) US $25MANITOBA051 Manitoba (Winnipeg) US $25NEW BRUNSWICK/ NOVA SCOTIA091 Maritime Chapter Chapter CollectsNEWFOUNDLAND & LABRADOR063 Newfoundland & Labrador (St. John’s)Chapter CollectsONTARIO062 Canadian Capital (Ottawa) US $30035 Ontario (Toronto) US $46.25PRINCE EDWARD ISLAND091 Maritime Chapter Chapter CollectsQUEBEC025 Quebec (Montreal) US $50SASKATCHEWAN064 Saskatchewan (Saskatoon/Regina) US $100JAPAN103 Japan (Tokyo) Chapter CollectsMEXICO104 Mexico (Monterrey) Chapter CollectsAll dues subject to change.Chapter Collects = chapter will invoicedirectly for chapter dues.3

Article IV - Membership Part ARIMS Constitution and BylawsJoin Today • www.RIMS.org/JoinTodayARTICLE IV - MEMBERSHIPSection 1. Classes of Membership.A. Class I - Corporations or Other Legal Entities(hereinafter “Member”)1. A Member corporation or legal entity must:• subscribe to the objectives of RIMS;• agree to abide by RIMS Constitution and Bylaws;• have been accepted for membership by a chapter,or for non-chapter membership by RIMS Directorof Membership & Chapter Services (or other staffequialent position) after taking into considerationgeographic location, travel time and otherextenuating circumstances;• at all times be represented by a Deputy (subject toeligibility requirements) who is a salaried employeeof the Member (or affiliated entity of the sameeconomic family); and• pay membership dues, which shall be fixed by RIMSBoard of Directors.A wholly owned subsidiary of a Member that has itsown risk management department and/or individual(s)performing the risk management function solely for thesubsidiary must have its own membership.2. A Member corporation or legal entity may:• designate two Deputies, a primary and asecondary, for its membership dues. The primarydeputy is responsible for exercising the voting rightsof the member organization with the secondarydeputy serving as the back up; and• designate additional deputies for a fee set by theBoard of Directors.3. A Deputy shall be a salaried employee of a Membercompany or affiliated entity of the same economicfamily having regular duties in risk or insurancemanagement and/or employee benefits management,who shall have been designated by a Member toexercise the rights of that member.A Deputy:a. must perform one or more of the following riskmanagement functions for the benefit of the Member,and if applicable, for an affiliated entity of the sameeconomic family:• risk administration;• risk assessment;• loss control;• risk financing; or• funding/selection/administration relative toproperty/casualty or employee benefits programs.b. must not engage in any of the following prohibitedactivities for any non-affiliated entities:• underwriting of insurance;• selling or brokering of insurance;• regulating of insurance;• rating of insurance;• ctuarial services relating to insurance;• investigation and/or settlement of losses;• providing risk management or employeebenefits-related services, including but not limitedto risk management consulting, rehabilitation,mediation, environmental services, disaster recovery,etc.;• providing legal services; or• executive recruitment and/or personnel recruitment.c. may vote, hold office and chair or serve on a committee.4