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To enroll in electronic billing for Workers' Compensation, Auto/No-Fault claims, an Authorized Corporate Representative must fill out the registration information below. Once registration is complete, you will receive a confirmation e-mail which will enable you to Login, add additional Users and begin setting up your Service Locations and Providers. All fields are required.

To begin electronically submitting your claims, please complete the registration form below.

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Please register your organization only once.

After you have registered you can add additional users. To do so, please log into your website and click on the ADMIN tab and select "Add Additional User". This screen will allow you to add users who will have access to your web site and claims.

First Name  
Last Name  
Account Name (Full)  
Account Nickname (Short - 3-16 letters)
The name assigned here will be part of every user's login ID, so be sure it is easy to remember & accurately representative of the account!
  
Contact Phone Number   
Tax ID  
Billing/Practice Location Address
Billing/Practice Location City
Billing/Practice Location State  
Billing/Practice Location Zip Code
Submission Type  
Approximate monthly claim volume  

 
Billing Company
E-Mail Address    
Confirm E-Mail Address    
Password (6-16 chars)   
Confirm Password    


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