Membership Application Apply online with the form below or download a PDF application and submit it by mail. General InformationMember Company*Primary Contact/Title*Secondary Contact/Title*Contact InformationCompany Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone*FaxPrimary Email* Accounting Email* Referred by:Type of MembershipPlease indicate your desired level of membership:*MemberAssociate MemberMembership is available to firms which are licensed as third party administrators under Texas law. Associate membership is made available to non-TPA firms which maintain a mutual interest in benefit administration in the state of Texas. Associate membership is for non-voting companies within the association.Amount of Annual Revenue/Billing - Annual Dues*$200,000 to $499,000Dues: $550$500,000 to $999,999Dues: $825$1 million plusDues: $1,100Dues are based on gross annual administrative revenue billings. Please select the appropriate level for your company.Does your company have one or more additional satellite offices?*YesNoPlease indicate the number of additional offices ($110/each)*12345678Contact and locations*Please list a primary contact and location for each additional office.License #Annual Dues$795In which of the following areas is your company involved? (Check all that apply)* 401k Plans Ancillary Coverages Auditing & Consulting Automated Software Systems Broker/Consultant Cafeteria Plans Claims Payor Systems COBRA Administration Dental Disability Plans DMO EAP FSAs Fully Insured HMO HRAs HSAs Managed Care Medical Cost Containment MEWAs MGUs MSAs Non-Subscriber Pension Benefit Plans Pharmacy Benefit Managers PPO Reinsurer Section 125 Plans Self-Funded Plans Stop-Loss Insurer Subrogation Servicces Utilization Review Vision Plans Wellness Worker's Comp. Plans Other Dues Total: $0.00 Payment Options:* Check To pay by check, please submit this application and send a check by mail to the following address: Texas Association of Benefit Administrators 6009 W. Parker Rd. #149-131 Plano, TX 75093 Credit Card To pay by credit card, please contact Phyllis Campbell at email@example.com or by phone at (512) 507-7001. You will be provided with an invoice that will allow you to pay through a secure payment terminal.Please select your preferred method of payment.CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.