Printable Registration - National Conference of Insurance Legislators

NCOIL 2015 Spring Meeting
February 27 through March 1, 2015 • The Mills House Wyndham Grand Hotel
you can also register online at www.ncoil.org
Name: _______________________________________________________
•
Charleston, South Carolina
Title: ____________________________________________________
Company/Affiliation: _____________________________________________
E-mail: ___________________________________________________
Preferred Mailing Address: ______________________________________
Accompanied By: __________________________________________
(Guests attending any NCOIL function must register.
Legislators’ guests are not subject to registration fee.)
_____________________________________________________________
_____________________________________________________________
Phone: ______________________
Fax: ______________________
Agent Continuing Education? c IL c KY c MS c WV
First Time Attendee? c Yes c No
__________________________________________________________________________________________________________________________
REGISTRATION
REGISTRATION WILL NOT BE PROCESSED WITHOUT PAYMENT
FEE SCHEDULE FULL REGISTRATION:
$375.00
____ Legislator, staff (contributing member state)
____ Legislator, staff (general member state)
$500.00
____ Industry Education Council (IEC)
$525.00
____ Industry (non-IEC) and all others
$775.00
____ Academics, think tanks (non-IEC)
$775.00
____ Consumer/advocacy groups (upon NCOIL approval) $375.00
____ Insurance commissioner or designated insurance
no charge
department staff person (one)
____ Insurance department (other)
$500.00
____ All other state/federal agencies
$500.00
____ Media
no charge
____ Non-legislative spouse/immediate family
$75.00
FEE SCHEDULE ONE DAY REGISTRATION:
FRI_
____ Legislator, staff (contributing member state)
____ Legislator, staff (general member state)
____ Industry Education Council (IEC)
____ Industry (non-IEC) and all others
____ Academics, think tanks (non-IEC)
____ Consumer/advocacy groups (upon NCOIL approval)
____ Insurance department (other)
____ All other state/federal agencies
SAT_ SUN_
$200.00
$262.50
$275.00
$400.00
$400.00
$200.00
$262.50
$262.50
POST-JANUARY 27:
$475.00
$600.00
$625.00
$875.00
$875.00
$475.00
no charge
$600.00
$600.00
no charge
$75.00
POST-JANUARY 27:
$300.00
$362.50
$375.00
$500.00
$500.00
$300.00
$362.50
$362.50
PAYMENT TO NCOIL
Date form was submitted _________________
c Registration fee enclosed
$____________________ (payable to NCOIL)
c Credit Card Payment
American Express
MasterCard
Visa
c
c
c
Card # _______________________________
_____________________________________
Exp. Date ___________ Code ___________
Signature _____________________________
CANCELLATION POLICY: FULL REFUND MINUS $75 PROCESSING FEE UP TO JANUARY 30; HALF REFUND UP TO FEBRUARY 6;
NO REFUND AFTER FEBRUARY 6. CANCELLATIONS WILL ONLY BE ACCEPTED IN WRITING.
You should receive notice from NCOIL confirming your registration within one week of submittal.
For Internal Use Only
ID# _________________
Reg. # _________________
Processed _____/_____/_____
HOTEL CUT-OFF DATE IS JANUARY 30, 2015
Rooms in the NCOIL room block are limited in number and may sell out prior to
this date. If rooms sell out, NCOIL will apprise you of overflow options.
HOTEL RESERVATIONS CANNOT BE MADE WITHOUT PAID MEETING
REGISTRATION. CHANGES TO ROOM RESERVATIONS AFTER ROOM
IS CONFIRMED BY NCOIL MAY RESULT IN PENALTIES.
HOTEL ACCOMMODATIONS NEEDED? c YES c NO
Legislators
All Others
c $159.00*
c $199.00*
* Plus taxes and fees currently totaling approximately 13.5%
Arrival Date: _____/_____/_____
Departure Date: _____/_____/_____
Room preferences: ______________________________________________
Any changes made within 7 days of arrival will result in a penalty equal to
the reduced number of nights. A cancelled reservation will result in a
charge of all nights originally booked. All changes must be made through
the NCOIL national office.
By _______
Conf. date ________
DB c
HOTEL PAYMENT
All room reservations must be guaranteed by an accepted credit
card or accompanied by a check equal to one night’s fee plus tax
made payable to the The Mills House Wyndham Grand Hotel.
Indicate below method of guarantee:
c Check Enclosed (amount: $_________________)
Charge to my:
c Same Account as Above
c MasterCard
c Visa
c American Express
c Discover
c Diners Club
Card #_______________________________________________
_____________________________ Exp. Date_____________
Signature ____________________________________________
The above signed authorizes the THE MILLS HOUSE WYNDHAM
GRAND HOTEL to charge this card for the initial deposit, as well
as for cancellations, no-shows & early departures.
_____________________________________________________________________________________________
NCOIL • 385 Jordan Road • Troy • NY • 12180 • Tel: 518-687-0178 • Fax: 518-687-0401
E-mail: info@ncoil.org • Website: www.ncoil.org