Membership Application

Use the form below to submit your application either by mail or electronically.When you hit continue you will be taken to a confirmation page. You can print the confirmation page and mail it to the address below or just click submit to email the registration.

WCCA
PO Box 1830
Lake Oswego, OR 97035
WCCA Tax ID 47-3268248
Dues ScheduleCompany / Individual Membership
Membership Dues$50 / $25

To determine your tier: count your Oregon workers’ comp technicians and supporting staff (managers, examiners, assistants, etc), those who manage or process claims, or are otherwise involved with claims management or workers’ compensation (case manager, risk manager, loss control, nurse case manager, vocational rehabilitation, etc).

    Membership Application Form

    Membership Form For *

    Membership Year

    Membership Dues

    Payment Options

    Check will be mailed within 5 daysCheck will be brought to the event

    Contact Person Name *

    First Name

    Last Name


    Company Name

    Email Address *

    Address

    Street Address

    Address Line 2

    City

    State / Province / Region

    Postal / Zip Code

    Country


    Phone Number

    (###)-###-####

    Fax Number

    (###)-###-####

    Business Type

    If Other Please Describe

     



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