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Access accounts/products through Insurance Solutions website
<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01//EN" "http://www.w3.org/TR/html4/strict.dtd"> <html> <head> <meta http-equiv="Content-Type" content="text/html; charset=windows-1252"> <title>Access accounts/products through Insurance Solutions website </title> <link rel="icon" href="/images/favicon.ico"> <link rel="stylesheet" type="text/css" href="/css/main.css" /> <link rel="stylesheet" href="/css/fontawesome.min.css" type="text/css"> <link rel="stylesheet" href="/css/bootstrap.css" type="text/css" /> <link rel="stylesheet" href="/css/jquery-ui-1.12.1.min.css" type="text/css" /> <link rel="stylesheet" href="/css/bootstrap-dialog.min.css" type="text/css" /> <script type="text/javascript" src="/js/jquery-3.5.1.min.js"></script> <script type="text/javascript" src="/js/jquery-ui-1.12.1.min.js"></script> <script type="text/javascript" src="/js/jquery.validate.min.js"></script> <script type="text/javascript" src="/js/additional-methods.min.js"></script> <script type="text/javascript" src="/js/bootstrap.min.js"></script> <script type="text/javascript" src="/js/aop.js"></script> <script type="text/javascript" src="/js/bootstrap-timepicker.js"></script> <script type="text/javascript" src="/js/bootstrap-dialog.js"></script> <script type="text/javascript" src="/js/moment.js"></script> <script type="text/javascript" src="/js/zulu-date.js"></script> <script type="text/javascript" src="/js/dashboard.js"></script> </head> <body> <div class="overlay text-center"> <h2><i class="fa fa-circle-o-notch fa-spin"></i> Loading...</h2> </div> <div id="main-body"> <header> <div class="row"> <div class="col-lg-5"> <div id="header-logo-div"> <a><img src="/images/LNRS_RGB_POS_1.png" alt="Lexis Nexis Risk Solutions" width="257" height="77"></a> </div> <div id="header-product-title"> <h1 class="product-title" title="Access accounts/products through Insurance Solutions website">Insurance Solutions - New User Request</h1> </div> </div> <div class="col-lg-7 padding-10"> <div class="header-menu"> <span class="footer-links"><a href="https://lnrs.my.site.com/CustomerSupportHub/s/contactsupport/ins-ip-insurance-portal-support" target="_blank">Chat</a></span> </div> </div> </div> </header> <div class="main-container-userform"> <div class="row"> <div class="col-lg-12"> <div class="padding-10 sub-container"> <input type="hidden" name="X_CSRF_TOKEN" value="2040eab6df81fe2043ce04ca1d49f37e59112ef4aec8dc9c1494a72b788cbfcd"> <input type="hidden" name="user_method" value=""> <form id="user-id-form" class="margin-top-10"> <div class="accordion"> <div class="card border-bottom"> <div class="card-header"> <span class="pull-left"><h6 class="mb-0"> User ID Request Form </h6></span> </div> <div class="collapse show"> <div class="card-body"> <p>Please enter all the information about the user you are requesting a User ID for below</p> <div class="row"> <div class="col-lg-12 form-horizontal"> <fieldset> <legend>Account Information</legend> <div class="form-group"> <label class="control-label col-md-3">Node ID/Account Number</label> <div class="col-md-9"> <input type="text" name="NodeOrAccount" class="form-control input-xs"> <label>If you don't have or know your Node ID or Account Number, leave this field blank.</label> </div> </div> <div class="form-group"> <label class="control-label col-md-3">User Type <i class="fa fa-asterisk color-danger"></i></label> <div class="col-md-9"> <input type="radio" name="UserType" required value="agent"> Agent <input type="radio" name="UserType" required value="underwriter" checked> Underwriter </div> </div> </fieldset> <fieldset> <legend>User Information</legend> <div class="form-group"> <label class="control-label col-md-3">First Name <i class="fa fa-asterisk color-danger"></i></label> <div class="col-md-9"> <input type="text" name="UserInfo.FirstName" class="form-control input-xs" required> </div> </div> <div class="form-group"> <label class="control-label col-md-3">Last Name <i class="fa fa-asterisk color-danger"></i></label> <div class="col-md-9"> <input type="text" name="UserInfo.LastName" class="form-control input-xs" required> </div> </div> <div class="form-group"> <label class="control-label col-md-3">Mother's Maiden Name <i class="fa fa-asterisk color-danger"></i></label> <div class="col-md-9"> <input type="text" name="UserInfo.MaidenName" class="form-control input-xs" required> <label>For security purposes</label> </div> </div> <div class="form-group"> <label class="control-label col-md-3">National Producer Number (NPN)</label> <div class="col-md-9"> <input type="text" name="UserInfo.Npn" class="form-control input-xs" maxlength="10" digits=true> <label>We are capturing the NPN to electronically verify the agent license and to improve the setup process for our customers</label> </div> </div> <div class="form-group"> <label class="control-label col-md-3">Email Address <i class="fa fa-asterisk color-danger"></i></label> <div class="col-md-9"> <input type="email" name="UserInfo.Email" class="form-control input-xs" required> </div> </div> <div class="form-group"> <label class="control-label col-md-3">Confirm Email Address <i class="fa fa-asterisk color-danger"></i></label> <div class="col-md-9"> <input type="text" name="ConfirmEmailAddress" class="form-control input-xs" required equalTo="[name='UserInfo.Email']"> </div> </div> <div class="form-group"> <label class="control-label col-md-3">Telephone <i class="fa fa-asterisk color-danger"></i></label> <div class="col-md-9"> <input type="text" name="UserInfo.Telephone" class="form-control input-xs" placeholder="(XXX)-XXX-XXXX" required phoneUS="true"> </div> </div> <div class="form-group"> <label class="control-label col-md-3">Fax</label> <div class="col-md-9"> <input type="text" name="UserInfo.Fax" class="form-control input-xs" placeholder="(XXX)-XXX-XXXX" phoneUS="true"> </div> </div> </fieldset> <fieldset> <legend> Agency/Company Information </legend> <p> <b>Agents</b> please provide your agency's information. <b>Underwriters, please provide your company information</b> </p> <div class="form-group"> <label class="control-label col-md-3">Agency/Company Name <i class="fa fa-asterisk color-danger"></i></label> <div class="col-md-9"> <input type="text" name="AgencyInfo.AgencyOrCompanyName" class="form-control input-xs" required> </div> </div> <div class="form-group"> <label class="control-label col-md-3">Address <i class="fa fa-asterisk color-danger"></i></label> <div class="col-md-9"> <input type="text" name="AgencyInfo.Address" class="form-control input-xs" required> </div> </div> <div class="form-group"> <label class="control-label col-md-3">City <i class="fa fa-asterisk color-danger"></i></label> <div class="col-md-9"> <input type="text" name="AgencyInfo.City" class="form-control input-xs" required> </div> </div> <div class="form-group"> <label class="control-label col-md-3">State <i class="fa fa-asterisk color-danger"></i></label> <div class="col-md-9"> <select name="AgencyInfo.State" class="form-control input-xs" required> <option value="">Please select one</option> <option value="AL">ALABAMA</option> <option value="AK">ALASKA</option> <option value="AB">ALBERTA</option> <option value="AS">AMERICAN SAMOA</option> <option value="AZ">ARIZONA</option> <option value="AR">ARKANSAS</option> <option value="BC">BRITISH COLUMBIA</option> <option value="CA">CALIFORNIA</option> <option value="CO">COLORADO</option> <option value="CT">CONNECTICUT</option> <option value="DE">DELAWARE</option> <option value="DC">DISTRICT OF COLUMBIA</option> <option value="FL">FLORIDA</option> <option value="GA">GEORGIA</option> <option value="GU">GUAM</option> <option value="HI">HAWAII</option> <option value="ID">IDAHO</option> <option value="IL">ILLINOIS</option> <option value="IN">INDIANA</option> <option value="IA">IOWA</option> <option value="KS">KANSAS</option> <option value="KY">KENTUCKY</option> <option value="LA">LOUISIANA</option> <option value="ME">MAINE</option> <option value="MB">MANITOBA</option> <option value="MD">MARYLAND</option> <option value="MA">MASSACHUSETTS</option> <option value="MI">MICHIGAN</option> <option value="MN">MINNESOTA</option> <option value="MS">MISSISSIPPI</option> <option value="MO">MISSOURI</option> <option value="MT">MONTANA</option> <option value="NE">NEBRASKA</option> <option value="NV">NEVADA</option> <option value="NB">NEW BRUNSWICK</option> <option value="NH">NEW HAMPSHIRE</option> <option value="NJ">NEW JERSEY</option> <option value="NM">NEW MEXICO</option> <option value="NY">NEW YORK</option> <option value="NL">NEWFOUNDLAND AND LABRADOR</option> <option value="NC">NORTH CAROLINA</option> <option value="ND">NORTH DAKOTA</option> <option value="MP">NORTHERN MARIANA ISLANDS</option> <option value="NT">NORTHWEST TERRITORIES</option> <option value="NS">NOVA SCOTIA</option> <option value="NU">NUNAVUT</option> <option value="OH">OHIO</option> <option value="OK">OKLAHOMA</option> <option value="ON">ONTARIO</option> <option value="OR">OREGON</option> <option value="PA">PENNSYLVANIA</option> <option value="PE">PRINCE EDWARD ISLAND</option> <option value="PR">PUERTO RICO</option> <option value="QC">QUEBEC</option> <option value="RI">RHODE ISLAND</option> <option value="SK">SASKATCHEWAN</option> <option value="SC">SOUTH CAROLINA</option> <option value="SD">SOUTH DAKOTA</option> <option value="TN">TENNESSEE</option> <option value="TX">TEXAS</option> <option value="VI">UNITED STATES VIRGIN ISLANDS</option> <option value="UT">UTAH</option> <option value="VT">VERMONT</option> <option value="VA">VIRGINIA</option> <option value="WA">WASHINGTON</option> <option value="WV">WEST VIRGINIA</option> <option value="WI">WISCONSIN</option> <option value="WY">WYOMING</option> <option value="YT">YUKON</option> </select> </div> </div> <div class="form-group"> <label class="control-label col-md-3">ZIP <i class="fa fa-asterisk color-danger"></i></label> <div class="col-md-9"> <input type="text" name="AgencyInfo.Zip" class="form-control input-xs" required zipcodeUS="true"> </div> </div> </fieldset> <fieldset> <legend>IP Address Information</legend> <p>Please supply an IP Address or IP Address Range (below) for each physical locations</p> <div class="form-group"> <label class="control-label col-md-3">IP Address Range <i class="fa fa-asterisk color-danger"></i><p><a href="https://support.lexisnexis.com/ipcheck" target="_blank">Click here to get your IP address</a></p></label> <div class="col-md-9"> <p>Only fill out one IP Address if you do not have a range assigned to you</p> <div class="pull-right margin-bottom-10"> <button class="btn btn-default" id="add-user-ip" type="button"><i class="fa fa-plus-circle"></i> Add</button> </div> <div class="margin-top-10"> <table class="table table-bordered table-striped"> <thead> <tr> <th>Start IP Address</th> <th>End IP Address</th> <th>Action</th> </tr> </thead> <tbody> <tr> <td> <input type="text" name="IPAddresses.0.StartIP" class="form-control input-xs" placeholder="Starting IP Address" required ipv4="true"> </td> <td> <input type="text" name="IPAddresses.0.EndIP" class="form-control input-xs" placeholder="Ending IP Address" ipv4="true"> </td> <td> </td> </tr> </tbody> </table> </div> </div> </div> </fieldset> <fieldset> <legend>Confirmation</legend> <p>I have read and agree to the terms of this document and hereby confirm that by marking the checkbox below, I have electronically signed this document. I understand that by inserting my electronic signature hereto, that I am legally bound by the terms and conditions of the form as if I had manually signed it.</p> <p> <input type="checkbox" name="confirm" required value="1"> By clicking this box: (a) I agree to the terms set forth in the above confirmation; and (b) I confirm that all information submitted by me is accurate and truthful. </p> </fieldset> <p class="text-center"> <button class="btn btn-default" type="reset">Reset</button> <button class="btn btn-default" id="submit-user-form">Submit</button> </p> <p> Note: Upon receipt of this form by LexisNexis, you as User will be issued a <b>User ID, </b>which is your key to entry into the LexisNexis automated information systems. This USER ID is assigned <b><a>ONLY TO YOU,</a></b> and is <b><a>NOT</a></b> to be transferred, shared or used by anyone else , including, but not limited to anyone else within your business. </p> </div> </div> </div> </div> </div> </div> </form> </div> </div> </div> </div> <div class="userform"> <div class="row"> <div class="col-lg-12"> <span class="blue-link"><a href="https://risk.lexisnexis.com/copyright" target="_blank">Copyright2025 ©</a></span><span class="text-bold"> LexisNexis Risk Solutions</span> <span class="footer-links"><a href="https://risk.lexisnexis.com/terms/" target="_blank">Terms & Conditions</a> | <a href="https://risk.lexisnexis.com/corporate/privacy-policy" target="_blank">Privacy</a></span> </div> </div> </div> </div> </body> </html>