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.

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 *


Street Address

Address Line 2


State / Province / Region

Postal / Zip Code


Phone Number


Fax Number


Business Type

If Other Please Describe


If others in your company would like to be added to the mailing list, click here.

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