Registration: Please note this is for members and agents only. Medical facilities seeking information on claims are to contact
payments@employersclaim.com
Username:
*
Username must be 6-200 characters long and can only contain letters, numbers and the following special characters: .!@#$%^&*_+=?~|- (Example: john.smith_14)
Email:
*
Example: someone@somedomain.com
Password:
*
Password must be 6-64 characters long with at least one letter, one number and one of the following special characters: .!@#$%^&*_+=?~|-
Password Confirmation:
*
First Name:
*
Last Name:
*
Organization Name:
*
Job Title:
Phone:
Extension:
Fax:
Example: 999-999-9999
Address Line 1:
Address Line 2:
City:
State:
Zip:
Example: 99999-9999
Comments:
Thank you for your registration!
