Gateway - Register

Adjuster Registration

Attorney Registration

Please Choose Role:

User Name/Email:

First Name:

Last Name:

Mailing Address

Address:

City:

State:

Zip code:

Phone Number:

Carrier Details

** FEIN/Name must be that of the carrier, TPA or self-administered self-insured employer completing the registration.

Carrier FEIN:

Carrier Name:

(Multiple Carrier/FEINs can be added)

User Name/Email

Primary Role

First Name

Last Name

Attorney Number

Mailing Address

City

State

Zip Code

Include Address In Public Directory

Phone Number

Include Phone In Public Directory

Firm Details

Name

Phone Number

Website

Include Firm Detail in Public Directory

Attorney Assistants Details

Email Notice(s)

Assistant1 First Name

Last Name

Email Notice

Assistant2 First Name

Last Name

Email Notice

Assistant3 First Name

Last Name

Email Notice

Oath

The undersigned affirms under the penalties for perjury that they have been duly admitted to practice in the Circuit and/or Superior Courts and the Supreme Court of the State of Indiana, and are in good standing as a practitioner before these Courts on the date of this Oath.

User Name/Email

First Name

Last Name

Password

Confirm Password

Worker's Compensation Board of Indiana Gateway

THIS IS QA/TEST SYSTEM

Adjuster Registration

Attorney Registration

Mailing Address

Carrier Details

Firm Details

Attorney Assistants Details

Oath