Register For Your Online Account

Thank you for your interest in our self-service benefit administration portal.

Please allow 5 - 7 business days for your request to be processed. Once approved, you will receive an email with your login information.

All fields are required.

Your Information

Group Name

Group Number

How do you currently send in eligibility

First Name

Last Name

Title

Phone Number

Street Address

Zip/Postal Code

Email (This will be your username)

Confirm Email

Password

Confirm Password