WILG Online Membership Application Form

Identify Yourself

Click the Account Lookup button to the left. Enter the search criteria and click Continue. If you see your name, please press the Choose button next to your name. If you do not see your name, click the Create an Account link

Enter your last name (and optional first name or first initial) in the Account Locator and click Continue.

Contact Information

Prefix:

*First Name:

Middle Name:

*Last Name:

Nickname:

Firm:

*Address:

*City:

*State:

*Zip:

*Business Phone:

(XXX-XXX-XXXX)

Business Fax:

(XXX-XXX-XXXX)

*Email:

Firm's Website:

Name of WILG Sponsor:

Date of Birth:

Bar Admission Year:

Application Date:

Gender:

Race:

Sexual Orientation:

How many members in your firm?:

Associations' Membership

Are you a member of:

AAJ Other

Other TLAs: Other Associations:

Voluntary Contribution

I want to add a voluntary contribution in the amount of $100.00 to help WILG's State and Federal Legislative efforts.

Auto-Renew Membership

Your Membership will automatically renew using the provided method of payment

*Membership Statement

I swear under penalty of perjury that I do not represent the interests of the insurance industry or employers.