Business Insurance Free Subscription

	*Business Insurance* is free to qualified professionals. Summary Description
	To apply for a FREE subscription to *Business Insurance, please answer ALL of the questions on the form below.If you qualify, you'll receive a free, 3 month trial subscription to Business Insurance*.
	The publisher determines qualification and reserves the right to limit the number of free subscriptions.
	Geographic Eligibility: USA

1.	*Please start my free 3 month trial subscription to Business Insurance.*

Yes No

First Name:
Last Name:
Job Title:
	(Ex: Director, Vice President, Project Manager, etc.)
Company:
	(Please provide your Company Name in full: abbreviations could disqualify you)
Street Address:
Suite/Floor:
City:
State:
Zip:
Country:
	(Note: If your country is not listed above, subscriptions are not currently available at your location.)
Phone:
Fax:
Email Address:
	(Note: Valid email address is required or you could be disqualified.)

As a subscriber to Business Insurance, you will also receive BI Daily News Alert and This Week in BI email products. I do not wish to receive:

BI Daily News Alert
This Week in BI
I prefer not to receive information on advertising from companies not affiliated with Business Insurance.

Yes, please auto-fill my contact information for other publication qualification forms.

2.	Please indicate which of the following best describes your title or job function? (select only one)

CEO/COO/President/Owner VP/GM/Dir/Mgr of: Health and/or Group Insurance

CFO/VP of Finance VP/GM/Dir/Mgr of: Pensions & Profit Sharing/Compensation

Controller/Secretary/Treasurer VP/GM/Dir/Mgr of: Corporate Management

Financial title other than CFO Accountant

General Counsel/Attorney Actuary, Adjuster, Appraiser

VP/GM/Dir/Mgr of: Risk Management Captive Manager

VP/GM/Dir/Mgr of: Employee Benefits/Human Resources Insurance Agent/Broker, Intermediary

VP/GM/Dir/Mgr of: Insurance/Property Casualty Insurance Underwriter, Insurer

VP/GM/Dir/Mgr of: Claims Other Adminstrative Titles

VP/GM/Dir/Mgr of: Workers Compensation Other (please specify)

VP/GM/Dir/Mgr of: Safety & Security

3.	Please indicate which of the following best describes your business/industry? (select only one)

Accounting Firms Insurance and Reinsurance Companies

Actuarial/Adjuster/Appraiser Firm Law Firms

Association Manufacturing/Service Firms

Captive Management Technology

Financial Claims/Third-Party Administration

Government/Union/Educational Institution Other (please specify)

Health Care Provider

Insurance Agency, Brokerage, Consulting Firm

4.	Number of persons employed by your organization: (select only one)

1 - 150 1,000 - 4,999

151 - 499 5,000 or more

500 - 999 Unknown

5.	Please indicate the extent to which you are involved in the purchasing decision for your employer's risk management and/or employee benefits products and services: (select only one)

Highly Involved Not Involved

Somewhat Involved I am a provider of these services

6.	For purposes of verification, please provide the state you were born in:

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* Note that a valid email address is required to fulfill your request. Please verify that the email and mailing address you provided are accurate before hitting the submit button.

* The publisher reserves the right to limit the number of free subscriptions and/or reject requests based on information provided.