LHCA: Registration

Register for the 89th LHCA Meeting by completing the following:

Click here to submit a question for the meeting.

* = REQUIRED

First Name: *

Last Name: *

Title: *

Company: *

Address: *

City: *

State: *

Zip: *

Phone: *

Fax:

E-mail: *

List Any Industry Designation(s):

Check All That Apply:

This is my first Life and Health Compliance Association Meeting
Plan on bringing a laptop computer and need plug in capability
Member of Handout Committee
Sponsor
Executive Committee

Registration Fee Information:

	Registration Fee (postmarked after 04/25/2008):	$475.00
	Number of Guests:	$175.00 per guest	$
Total Registration Fee:			$

*Guest fee includes the same breakfast, lunch and reception events provided to the registrant.

Please make registration fee checks payable to "Ameritas Life Insurance Corp." and mail them to:

Cindy Meyer
Ameritas Life Insurance Corp.
5900 O Street
P O Box 81889
Lincoln, NE 68501-1889

Cancellation Policy:
Cancellations received prior to May 1, 2008 will be refunded 50% of the registration fee. After that date there will be no refunds. Registration may be transferred to a different attendee from your company (for this meeting only) without penalty.

Guest Information:

Name of Guests — list names exactly as you want them to appear on name tag

Guest 1 Name:
Guest 2 Name:
Guest 3 Name:
Guest 4 Name:

If you are registering more than 4 guests, please provide the names of the additional guest to "e-mail address for the host company"

Special Considerations for Registrant and Guests:
Please list any dietary or physical limitations needing special consideration

Golf Information:

	Number of Golfers @ $60/per
	If necessary, will you have a car available for transportation to the golf course?
	If yes, how many golfers could ride with you?
Total Golfing Fee: $

Total Charges:

Total Registration and Golfing Fees: $

Additional Information to be included on attendee lists.
Please mark all that apply:

My company has:
Life Insurance
Variable Life
Equity Indexed Life
Pre-need
Annuities
Variable Annuities
Equity Indexed Annuities
Credit
Health Insurance
Major Medical
Managed Care
Long-Term Care
Medicare Supplement
Disability Income
Specified Disease
Other: