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New User Request Form
Asterisk '*' Marked Fields are Required
Requestor Information
1
*Requestor Name
2
*Member Name (School District)
3
*Requestor Email Address
4
*Phone Number
[Area Code] [Phone Number]
New User Access Information
5
*New User Name
6
*New User Email Address
7
*Phone Number
[Area Code] [Phone Number]
8
*Access Student Accident Claims Only
Yes
No
