New client enrollment Company Name* Company Contact Name* Street City State / Region / Province Zip CodePhone Number*Fax Number*Number of employees*1 – 2526 - 5051 -100101 – 200201 – 500>500Employer Portal Access desired*NoYesPortal Display name* Contact Name* Email* Temporary Password* Phone*Fax*Worker’s Compensation Information*Bill ToEmployer* Insurance* Contact* Phone*Fax*Email* Transcription Delivery*MailFaxEmailMail*YesNoFax*YesNoFax Number*Email*NoYesEmail* Temporary Password*
