Workers' Compensation Commission


Please complete the fields below and select submit form for WCC approval. No access is available until your application process is completed. All fields marked with an * are required. Additional help with the application can be found HERE.

Email:*User ID, e.g., must be unique to each subscriber
Authorized Official First Name:*First Name
Authorized Official Middle Name:Middle Initial or Middle Name
Authorized Official Last Name:*Last Name
Authorized Official Title/Position:*Position Title
Authorized Official Work Phone:*Work Phone
NPI:*National Plan and Provider Enumeration System assigned unique National Provider Identifier (NPI)
Organization Name:*Business Name (as insured or registered)
Street Address 1:*Address 1
Street Address 2:Address 2
ZIP:*ZIP Code, e.g. 12345-6789, last 4 digits optional
Taxonomy:*Provider Type