Provider and Advocate Registration

Please complete all of the fields in order to  setup your organization for the Victims Comp Portal.
 
All organizational setups will be reviewed and access will be granted to the Director or CJCC primary contact.  It will be the responsibility of the Director or primary contact to manage the account setup for their organization's users.  
 
Allow up to 5 business days to confirm the registration request.

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* 1. Requester's Name (First and Last)

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* 2. Requester's Email address

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* 3. Requester's Phone number

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* 4. Agency/Organization Name.  Please list any variations of names that the organization is known by.

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* 5. Please select the phrase that best describes your organization?

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* 6.
Agency/Organization's Mailing Address

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* 7. Organization's Director or Primary Contact Name (First and Last)

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* 8. Director's or Primary Contact's Email address

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* 9. Provide the account or claim number from at least 3 recent bills or claims to verify your identity.

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* 10. If you currently receive payments from Victims Compensation Division, or anticipate doing so in the future, then please provide the primary financial contact for your organization (E-mail/phone)?

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* 11. FEI Number (if applicable)

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