Sample text to request an initial user name and password

If you opt to use this text, it must be printed on your agency letterhead to be valid.

This is an application to obtain access to our agency information in the secure area of the State Insurance Fund's web site.

My signature on this application authorizes the State Insurance Fund to issue a user name and password to the person named below. This person will act as our Agency Administrator and will have the ability to add and delete other users at our agency.

Please send the user name and password to:

_________________________________ (full name)

_________________________________ (preferred user name)

_________________________________ (e-mail address)

_________________________________ (contact number)


__________________________________(SIF agency number)

__________________________________ (signature)

The State Insurance Fund is not responsible for unauthorized access granted by the administrator in your agency.