Member Agency Client Enrollment Form

Software tools for risk management and insurance professionals

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WorkCompEdge Client Enrollment Form To enroll your clients in WorkCompEdge, simply complete the enrollment form below. After we process the registration, we will email the addresses you've indicated (and copy you) with WorkCompEdge access details. Please allow one business day for us to process registration (although usually it takes just an hour or two during normal business hours.)

Please provide the following contact information. An '*' denotes required fields:

Information about you:

Your Name *

Your Email Address *

Your Company Name *

Member Agency ID *

Information about your client:

Primary Contact Name *

Company *

Address *

City, State and Zip *

Phone w/area code *

E-mail address *

If you have problems using this form or do not hear from us within one business day,
please call us at 800-929-4052 x 201 to confirm your registration.