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Employee Self Registation - Step 1

This is the first of a multi-step process to gain access to the enhanced features of this site. We will be using the information you provide below to validate your eligibility for those services and to start setting up your account. Once you submit this form you will receive an e-mail (to the address you specify below) containing a link, clicking on this link will bring you to the next step in your registration process.

Shows required fields.


Employer Information

Division Number
Please obtain from your employer.

Policy Information

Date of Birth
Medical ID Number
Located on your Horizon Blue Cross insurance card.

Contact Information

First Name
Middle Initial
Last Name
Optional Line 2
Phone Number
Cell Number
Fax Number
E-mail Address
Confirm E-mail Address

Login Information

User Name
Requirements: 8 or more Characters,
1 Capital, 1 Lowercase, 1 Number & 1 Special.


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