BILTIR Membership Application

New Membership

Companies are invited to become a member of Bermuda International Long Term Insurers and Reinsurers. Please complete this membership application together with the Form A and Proxy below and submit it with the membership fee payable to BILTIR.

Membership Renewal

Existing member companies wishing to renew on-line, please complete the following information and submit your payment using one of the options listed below.

If there have been any changes to your company details, representative or proxy information, please complete the Form A and Proxy below and submit to BILTIR with your membership renewal fee.

Form A

TO: The Directors of Bermuda International Long Term Insurers and Reinsurers (the “Company”)

We,

, apply to be admitted as a Member of Bermuda International Long

Term Insurers and Reinsurers.

We agree to become a Member subject to the Memorandum of Association and the Bye Laws of the Company and authorize you to enter the following name and address in the Register of Members of the Company:

PROXY (For Full Members only)

TO: The Directors of Bermuda International Long Term Insurers and Reinsurers (the “Company”)

Signed by or on behalf of the above-named:

Signed by or on behalf of the above-named:

Payment Information