Workers' Compensation Commission

INSURER DELEGATE

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. george@whitehouse.gov, must be unique to each subscriber
Password:*8-12 Chars with at least 1 number
Confirm Password:*Must match previous field
First Name:*First Name
Middle:Middle Initial or Middle Name
Last Name:*Last Name
Suffix:Suffix, .g. Sr., Jr., III, Esquire
Street Address 1:*Address 1
Street Address 2:Address 2
City:*City
State:*State
ZIP:*ZIP Code, e.g. 12345-6789, last 4 digits optional
Work Phone:*Day Phone, e.g. 111-222-3333
Mobile Phone:Mobile Phone, e.g. 111-222-3333