CONFERENCE REGISTRATION REGISTRATION AREA: Mastercard and Visa Payments Only Please fill in the information requested below *REQUIRED FIELDS Title*: Dr Mr Mrs Ms Last or Family Name*: First and Other Names*: Business Title: Organisation*: Street Address*: City*: State: Zip Code: Country*: Business Phone*: E.g. 2464375608 Fax Number: E.g. 2464277277 Email*: (Please ensure the email above is correct as your payment transactions will be sent to this address.) Accompanying Spouse/Child: [Children under 16 - No charge)] Each additional person will incur an additional cost of US$250 SpouseChild over 15Child SpouseChild over 15Child CONFERENCE REGISTRATION [PROFILE] Please fill in the information requested below: *REQUIRED FIELDS Gender*: Male Female Professional Designation: Company Type*: Life Non-Life Composite Broker Agent Reinsurer Other If Other: provide info. IAC MEMBER*: YES NO LIMRA/LOMA MEMBER*: YES NO Number of IAC Conferences attended*: none Less than 5 Less than 10 Less than 15 More than 15 CONFERENCE REGISTRATION [REGISTRATION DETAILS] Please click the relevant check box below indicating if you are a Member, Non-member or an Exhibitor. IAC & limra loma (L/L) MEMBERS PACKAGE IAC NON-MEMBERS PACKAGE Exhibitors package Member Registration Fee: US$675 before April 30 US$725 after April 30 General Registration Fee: US$995 before April 30 US$1045 after April 30 General Registration Fee: US$500 before April 30 US$550 after April 30 General Registration MEMBER NON MEMBER EXHIBITORSAfter completing Conference Registration, please procees to Exhibition Booth Registration Number of persons attending: Conference Ceremonies Please indicate if you will be participating in the following activities* IAC Opening Ceremony (June 5th, 2016) IAC Closing Ceremony (June 7th, 2016) TOTAL COST for IAC Conference $US CREDIT CARD DETAILS Card Type: VISA MasterCard Card Number: XXXX -XXXX - XXXX - (Enter the last 4 digits of your Credit Card details above for the purpose of verification.) Cancellation Policy Any cancellations for registration will be refunded less US$100.00.Any cancellations received after April 30, , will NOT be refunded any part of the registation fee.