Enter your First and Last Name.

Enter your Employee ID. This ID was assigned by your Administrator and could be your Health Plan Member Number, Social Security Number, an ID provided by your Employer or an alternate ID created by your Administrator. If you do not know your ID or were not provided an ID, please contact your Administrator. This field is case sensitive.

Enter your Employer ID exactly as provided to you by your Administrator. If you don’t know your Employer ID or were not provided an ID, please contact your Administrator. You must enter either a Card Number or an Employer ID.

If you have been assigned a Benefits Card, enter the card number. Entering dashes between numbers is optional. If you have not been assigned a card, leave this field blank. You must enter either a Card Number or an Employer ID.

Enter a User ID to identify you to the system. You will use this User ID when logging into this system.

Enter a new password. Your password must meet the minimum security requirements. This field is case sensitive:

• Password must contain between 8 and 16 characters.
• Password must contain one instance of at least three of four types of characters:
  upper case, lower case, special character, and number.
• Password cannot contain the same character repeating 3 or more times,
  for example, “AAA” is invalid.
• Password cannot contain the word “password”.
• Password cannot be the same as a username.
• Password cannot contain spaces.

Please enter your Security Word or Mother's Maiden Last Name. It must be less than 30 characters. This word will be encrypted, stored in a secure database and is not used for any purpose other than to allow you access to your account should you forget your password.

Enter the city you were born in. It must be less than 30 characters. This word will be encrypted, stored in a secure database and is not used for any purpose other than to allow you access to your account should you forget your password.

Enter an E-mail address. This e-mail address will be used when sending emails to your Administrator and for other notification regarding your account.

Check this box if you wish to have statements and inquiries sent to your e-mail.