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Membership Referral
Thank you for the referral!
Please fill in the information below to refer a qualified TPA for membership in the TPAA. If the TPA becomes a member within 90 days of the date of this referral, we will send you a
$100 American Express Gift Card
as a thank you for your referral.
Your Contact Information
Are You A...
First Name:
TPA
Broker
Benefits Consultant
Self Funded Employer
Fully Funded Employer
PPO
PBM
MGU
Other (Please Specify Below)
Last Name:
Company:
Title:
Address 1:
Address 2:
City:
State:
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
Zip:
Email:
Tell us about the TPA that you think qualifies to be a member of the TPAA...
Additional Comments
First Name:
Last Name:
Company:
Title:
Address 1:
Address 2:
City:
State:
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
Zip:
Email:
Phone:
(Optional)
212 Church Street • Decatur, GA 30030 • Fax 404.377.2774 • 1.866.436.0188 • www.theTPAA.com •
admin@theTPAA.com
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