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Help SIIA Fight Unlawful Regulation of Stop-Loss Insurance
                                         Legal Defense Fund Pledge Form


    Overview The Self-Insurance Institute of America, Inc. (SIIA) is preparing a litigation strategy in response
    to anticipated action(s) at the state level to more tightly regulate stop-loss insurance attachment points. SIIA
    believes that such action(s) will have the effect of restricting the ability of many employers from self-insuring
    and the association’s legal counsel has concluded that there is a viable ERISA preemption challenge that can be
    presented in federal court. The particular state law(s) to be challenged will be dictated by future developments
    and subsequent analysis with regard to the likelihood of success.

    Financial Support Request                       SIIA expects that a litigation response will be costly, so it is
    seeking the financial support of its members and other industry stakeholders at this time in the form of
    pledges in order to confirm it will have the money necessary to mount a robust legal challenge at least
    through the trial court level, with the assumption that additional rounds of fund-raising will be required later
    to take this matter all the way to the U.S. Supreme Court if necessary.

    The association intends to collect on all pledges if and when it has decided on a specific course of legal action,
    again based on legislative/regulatory developments in various states. Financial contributions will be made to
    SIIA’s Legal Defense Fund, which is a segregated account used exclusively to pay for litigation related expenses.
    For contributions of $25,000 or more, your company will be provided one position on the litigation steering
    committee, which will be involved with strategy decisions.

    Questions? Should you have questions regarding this initiative, please contact SIIA Chief Operating
    Officer Mike Ferguson at 800/851-7789 (office), 864/363-2600 (cell), or via e-mail at mferguson@siia.org.


                       We Pledge the Following Financial Support
                                      (Only to be billed should litigation be initiated.)

	                 $50,000                $10,000                  $2,500                    Other $________
                  $25,000                $5,000                   $1,000


Contact Information
Name_______________________________________________ Title________________________________________
Company________________________________________________________________________________________
Address_________________________________________________________________________________________
Phone_______________________________________________ E-mail______________________________________

                              Please Return Completed Form to:
           SIIA P.O. Box 1237 • Simpsonville, SC 29681 or Email: mmachado@siia.org or Fax: 864/962-2483

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SIIA stop-loss legal fund

  • 1. Help SIIA Fight Unlawful Regulation of Stop-Loss Insurance Legal Defense Fund Pledge Form Overview The Self-Insurance Institute of America, Inc. (SIIA) is preparing a litigation strategy in response to anticipated action(s) at the state level to more tightly regulate stop-loss insurance attachment points. SIIA believes that such action(s) will have the effect of restricting the ability of many employers from self-insuring and the association’s legal counsel has concluded that there is a viable ERISA preemption challenge that can be presented in federal court. The particular state law(s) to be challenged will be dictated by future developments and subsequent analysis with regard to the likelihood of success. Financial Support Request SIIA expects that a litigation response will be costly, so it is seeking the financial support of its members and other industry stakeholders at this time in the form of pledges in order to confirm it will have the money necessary to mount a robust legal challenge at least through the trial court level, with the assumption that additional rounds of fund-raising will be required later to take this matter all the way to the U.S. Supreme Court if necessary. The association intends to collect on all pledges if and when it has decided on a specific course of legal action, again based on legislative/regulatory developments in various states. Financial contributions will be made to SIIA’s Legal Defense Fund, which is a segregated account used exclusively to pay for litigation related expenses. For contributions of $25,000 or more, your company will be provided one position on the litigation steering committee, which will be involved with strategy decisions. Questions? Should you have questions regarding this initiative, please contact SIIA Chief Operating Officer Mike Ferguson at 800/851-7789 (office), 864/363-2600 (cell), or via e-mail at mferguson@siia.org. We Pledge the Following Financial Support (Only to be billed should litigation be initiated.) $50,000 $10,000 $2,500 Other $________ $25,000 $5,000 $1,000 Contact Information Name_______________________________________________ Title________________________________________ Company________________________________________________________________________________________ Address_________________________________________________________________________________________ Phone_______________________________________________ E-mail______________________________________ Please Return Completed Form to: SIIA P.O. Box 1237 • Simpsonville, SC 29681 or Email: mmachado@siia.org or Fax: 864/962-2483