Membership Management System

Group Admin Registration

Please complete and submit the application. After submission, an email will be sent with further information. Please see Instructions below for more details.
Address: MWCIA, 7701 France Ave South, Suite 450, Minneapolis, MN 55435-3203
Fax: 952-897-6495

Registration Type*

Organization Name*

NCCI Group Number*

First Name*

Last Name*

Email*

Job Title

Department

Address*

City*

State*

Zip*

Phone*

Extension

Phone 2

Fax

User Information

User ID*

Must be 6 characters minimum; must begin with at least one ALPHA CHARACTER; can be all alpha or alpha-numeric beginning with alpha; no symbols;no common words; no spaces. If you have an existing UserID for the given NCCI Group Number, please use it.

Authorizing Officer for Group Administrator Applicant
Must be the president, owner, or a chief officer of the organization

First Name*

Last Name*

Title*

Phone*

Email*

Please attach a business card, or copy of a business card, of the authorizing officer for verification.

Applicant’s Agreement to Additional Terms and Conditions of Use is a part of this Application.

VERIFY MEMBERSHIP