Risk & Insurance Free Subscription

	*Risk & Insurance* is free to qualified professionals. Summary Description
	To apply for a FREE subscription to *Risk & Insurance, please answer ALL of the questions on the form below. If you qualify, you'll receive a free, 6 month trial subscription to Risk & Insurance*.
	The publisher determines qualification and reserves the right to limit the number of free subscriptions.
	Geographic Eligibility: USA, Canada, Bermuda, & Great Britain

1.	*Please start my free 12 week trial subscription to Risk & Insurance* (No payment information is required at this time).**

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2.	By providing your email address you are granting Risk & Insurance permission to contact you regarding your subscription. May Risk & Insurance use this email address to contact you about other product offerings?

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Company:
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3.	Is the above your company address?

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4.	Are you an agent/broker?

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5.	Primary business at this location: (select only one)

Agriculture, Forestry and Fishing Services (consultants, schools, universities, hotels, ad agencies)

Mining/Construction (contractors, builders) Public Administration (federal, state and local government, military)

Manufacturing Insurance

Transportation, Communications, Electric, Gas and Sanitary Services Hospital and Medical Services

Wholesale/Retail Trade (restaurants, chain stores) Other (please specify)

Finance, Banking and Real Estate

6.	Indicate your title: (select only one)

CEO, President, Chairman, Owner, Partner, Principal

CFO, Vice President (risk mgmt., insurance, finance, employee benefits, loss control, HR)

Asst. or Assoc. VP (risk mgmt., insurance, finance, employee benefits, loss control, HR)

Director (risk mgmt., insurance, finance, employee benefits, loss control, HR)

Manager (risk mgmt., insurance, finance, employee benefits, loss control, HR)

Insurance Broker, Agent, Consultant

Other (please specify)

7.	Number of employees in your entire company at all locations: (select only one)

25,000 or More 1,000 - 1,999

10,000 - 24,999 500 - 999

5,000 - 9,999 150 - 499

2,000 - 4,999 Under 150

8.	Check any and all areas for which you have purchasing and/or functional responsibilities for: (select all that apply)

Risk/Insurance Reinsurance

Alternative Risk Financing Workers' Compensation

Claims Administration Technology

Employee Benefits None of the above

Safety and Loss Control

9.	For purposes of verification, please provide the your state of birth:

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