Insurance Solutions - New User Request

User ID Request Form

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

Account Information

Node ID/Account Number

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

User Type

Agent Underwriter

User Information

First Name

Last Name

Mother's Maiden Name

For security purposes

National Producer Number (NPN)

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

Email Address

Confirm Email Address

Telephone

Fax

Agency/Company Information

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

Agency/Company Name

Address

City

State

ZIP

IP Address Information

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

IP Address Range

Click here to get your IP address

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

Start IP Address	End IP Address	Action

Confirmation

I have read and agree to the terms of this document and hereby confirm that by marking the checkbox 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.

By clicking this box: (a) I agree to the terms set forth in the above confirmation; and (b) I confirm that all information submitted by me is accurate and truthful.

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.

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User ID Request Form