Register

NEW REGISTRATION

Please select the option that is appropriate to you. If you are registering as other than a Guest User you will then be required to select your company name or department name from the drop down list that will be presented after you make this selection.

Registration in each state is not required. A single registration in either state will allow you to access both Pennsylvania and Delaware data.

User Type:*

Agency:*

Agency FEIN:*

Agency Name:*

Agent License:

Provide license number, if applicable. Select all that apply.

Non-Resident License

No License

Agent NPN:*

I am applying for the role of Agency Group Administrator:

Yes

Note: A Group Administrator is required for all companies. The Group Administrator must be appointed before access to the website can be approved for additional users. If there is no Group Administrator for your company, access will be denied.

An approved Agency Group Administrator (AGA) is required to register an insurance agency for access to the DCRB/PCRB Application Manager and the products contained therein. The AGA will be responsible for establishing and maintaining contact information and authorization for all user access for their Agency Group. The AGA will have the authority to view and control access for all users and applications.

The Agency Group Administrator must be appointed by the agency’s authorizing officer. The authorizing officer must be a controlling member of the organization, such as the President, Owner or Officer.

AUTHORZING OFFICER

Name:*

Title:*

Email:*

I understand and agree to the role and responsibilities of the Agency Group Administrator for the company listed on this form. I have read and understand the Terms of Service and Conditions of Use, as well as the Privacy and Security Statement, for the DCRB/PCRB website.

Employer:*

Employer FEIN:*

Employer Name:*

I am applying for the role of Employer Group Administrator:

Yes

An approved Employer Group Administrator (EGA) is required to register an employer for access to the DCRB/PCRB Application Manager and the products contained therein. The EGA will be responsible for establishing and maintaining contact information and authorization for all user access for their Employer Group. The EGA will have the authority to view and control access for all users and applications.

The Employer Group Administrator must be appointed by the company’s authorizing officer. The authorizing officer must be a controlling member of the organization, such as the President, Owner or Officer.

AUTHORZING OFFICER

Name:*

Title:*

Email:*

I understand and agree to the role and responsibilities of the Employer Group Administrator for the company listed on this form. I have read and understand the Terms of Service and Conditions of Use, as well as the Privacy and Security Statement, for the DCRB/PCRB website.

ABOUT YOU

First Name:*

Last Name:*

Email:*

Confirm Email:*

Be sure you enter your correct email address. Failure to do so will prevent you from receiving your account activation link to use this application.

Title:*

Phone Number:*

Phone Ext.:

Fax Number:

Company Name:*

Company Address:*

Company City:*

Company State:*

Company Zip Code:*

CREATE AN ACCOUNT

User Name:*

New Password:*

Cannot be same as username
Minimum length of 12 characters for non-admin accounts
Minimum length of 15 characters for administrator accounts
Contain at least 1 uppercase, 1 lowercase, 1 numeric and 1 special character from @ # $ % ^ & + ! =

Confirm Password:*

Security Question:*

Security Answer:*

Type the code shown:

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