Manage USR Application Login Req

Manage USR Application Login Request Form

Please complete the application and mail or fax to MWCIA.
Address:7701 France Ave South, Suite 450, Minneapolis, MN-55435-3200
Fax: 952-897-6495

Please provide following information.

Group ID:
Group Name:
Contact Name:
Street Address: City: State and Zip Code
Phone Number:
Fax Number:
E-Mail Address:
User Name:
Password:
Username/Password requirements: 6 characters minimum / Must begin with at least one ALPHA CHARACTER/can be all alpha or alpha-numeric beginning with alpha / all lower case / no symbols / no common words/no spaces/ login name and password should not be identical.
Please enter the Carrier ID and Name for which you want to view data.
No. Carrier ID Carrier Name
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(Above list may be reproduced to add additional Carrier Names)
CAUTION... ALL MANAGE USR DATA IS PROPRIETARY TO MWCIA’S MEMBER CARRIERS. ONLY MEMBER CARRIERS MAY REQUEST OR RECEIVE A LOGIN TO ACCESS DATA IN MANAGE USR. NO OTHER ENTITY MAY RECEIVE ACCESS TO MANAGE USR EXCEPT AS PROVIDED TO A THIRD PARTY DIRECTLY BY THE RESPONSIBLE CARRIER ITSELF. You will be notified when your application has been accepted. If there are any questions, please email us at manageusr@mwcia.org I have read and agree to the Disclaimer note on the Login Screen of the MWCIA Website regarding Website rules and procedures.
Signature:__________________________________________________ Date:______________