KidsVax

Important: This form is for new payers and new users only. If you have logged in successfully you may add additional payers within the assessment site.

Payer Registration Form

Program Access *

Federal EIN *

Format: 12-3456789

Please Provide a valid Federal EIN.

Company Name *

Please provide a valid company name.

Address 1 *

Please provide a valid address.

Address 2

City *

Please provide a valid city.

State *

Please select a valid state.

Zip *

Please provide a valid zip.

NAIC #

Group #

User Registration Form

This user will become the admin for the payer and will use the credentials made here to login to the assessment site(s).
The admin will be able to add additionals users and change information set here once successfully logged in.

Email *

Please provide a valid email.

First name *

Please provide a first name.

Last name *

Please provide a last name.

Address 1 *

Please provide a valid address.

Address 2

City *

Please provide a valid city.

State *

Please select a valid state.

Zip *

Please provide a valid zip.

Password

Please provide a valid password.

Confirm Password

Please confirm password.