Provider Application – Political Subdivision Workers Compensation Alliance

Tell us about the Applicant.

* Corporate Name as it appears on IRS W-9:

* Practice Name to appear in the directory:

* Tax ID
* Group NPI

Location 1 (required)

* Address
* Location NPI

* City

* ZIP Code

* County

Additional location

Provider 1

* First Name

* Last Name

* License Type

* License Number

* NPI Number

* Seeking Participation?

Specialty 1

Specialty 2

Specialty 3

Additional provider

Practice Hours (select all that apply)

* Name
Title
* Email
* Phone
Web site
Reason for recommendation
Comments

* This application is by * Nominator Name
* Title
* Phone
* Email