Form Center

By signing in or creating an account, some fields will auto-populate with your information.

Member Portal Login Request

  1. If you have any difficulties completing the form below, please contact Michele Keplinger at for assistance.

    To request an additional Member Portal user, please complete the form below.

  3. Are you a Main Contact, Main CC, or Administrator?

    In order to add a portal user, this form must be completed by a main contact or administrator.

  4. New User Information:
  5. 1) Policy Change Request Management
  6. 2) Policy Document Read
  7. 3) Policy Document Upload
  8. 4) Policy View Access
  9. 5) Renewal Edition Write
  10. 6) Claims

    Only the main contact or departmental contact designated by the main contact has the right to file an incident report or view incident or claim information because incident information is confidential.

  11. 7) Dashboard

    Users are given rights to the Analysis tab.

  12. Leave This Blank:

  13. This field is not part of the form submission.