User ID Request Form

Please enter all information about the user you are requesting a User ID for below.

Account Information

If you don't have or know your Node ID or Account Number, leave this field blank.

  

User Information


For Security Purposes

We are capturing the NPN to electronically verify the agent license and to improve the setup
process for our customers

(XXX) XXX-XXXX

(XXX) XXX-XXXX

Agency/Company Information

Agents, please provide your agency's information. Underwriters, please provide your company information

IP Address Information

  

Please supply an IP Address or IP Address Range (below) for each physical location.

  to  

Only fill out one IP Address if you do not have a range assigned to you.

Confirmation

I have read and agree to the terms of this document and hereby confirm that by marking the check box below, I have electronically signed this document. I understand that by inserting my electronic signature hereto, that I am legally bound by the terms and conditions of the form as if I had manually signed it.

Note: Upon receipt of this form by LexisNexis, you as User will be issued a USER ID, which is your key to entry into the LexisNexis automated information systems. This USER ID is assigned ONLY TO YOU, and is NOT to be transferred, shared or used by anyone else, including, but not limited to anyone else within your business.