Member Resource Form
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First Name
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Last Name
Organization/Company Name
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Address 1
Address 2 (optional)
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City State Zip
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Phones (Required)
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Email (Required)
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Company Website Address/URL
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Please indicate type of Workers Compensation services provided
(check all that apply):
Claims Management Services
Claims Service Providers
Consultants - Legal
Consultants - Medical
Consultant - Safety
Consultants - Workers' Compensation
Consultants - Other
Independent Medical Providers
Insurance/Reinsurance Services
Investigation & Surveillance Services
Legal Services
Medical Management Services
Medical Specialist - Chiropractors
Medical Specialists - Physical Therapists
Medical Specialists - Physicians
Medical Specialists - Other
Return-to-Work Specialists
Risk Control Services
Third Party Administrators
Vocational Rehabilitation Services
Other
Others
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Text Message for PSIA
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Indicates Response Required