Create a New Account

Important Notice:

  • This form is for new companies.

  • If your company may already have an account, you should reach out to your supervisor to request they create a new user account under your existing company profile.

  • If another branch of your company already has an account, but you wish to create a new account which handles billing independently, you may proceed but will need to enter a unique company name, for example if there is already an 'ABC Insurance' account you might enter 'ABC Insurance - Indianapolis Branch' as your company name.

  • If you are uncertain about any of these items, email

Company Profile

Company Name
Account Type
Description (optional)
Tax Id Number Address Address Two City
State Zip
Company Primary Claims Phone Company Primary Claims Email Primary Primary Claims Contact Name

Primary Administrator Login Account

First Name Last Name Email
Direct Phone Line Password Re-enter Password