Register an Individual Consumer · Custom Portal

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All Users must first create a username and password prior to using the Rapid Online Submission Interface.

An Individual/Consumer account is appropriate for businesses appealing a decision from their insurance carrier or the Worker's Compensation Insurance Rating Bureau (WCIRB), and for those applicants denied written consent from CDI's Legal Division.

User Info

First Name

*

Last Name

*

Company Name

*

Business Address

Address

*

2nd line of address (if needed)

*

City

*

State

*

Zip

*

Mailing Address (if different from Business Address)

Address

*

2nd line of address (if needed)

*

City

*

State

*

Zip

*

Contact Info

Phone (Work)

*

Phone (Cell)

*

Fax Number (if applicable)

*

Email Address

**

Confirm Email

*

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