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ILLINOIS CAPTIVE & ALTERNATIVE RISK FUNDING INSURANCE ASSOCIATION

Membership Application

Firm Name:__________________________________________________

Contact Person:_____________________________________________

Title:______________________________________________________

Street Address:_____________________________________________

City:_________________________  State:_______  Zip:_________

Firm Telephone:_______________  Direct Line:________________

FAX:________________   E-Mail:______________________________

The membership form that we used to have on this page is no longer accurate. Please contact Chad Kunkel for current information.

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2003 Contact Information:

Chad Kunkel
Gallagher Captive Services, Inc.
Two Pierce Place
Itasca, IL 60143
630-285-4176
630-285-4000 (fax)
chad_kunkel@ajg.com