Registration

Complete the Form below to apply for access to the MRPIUA website general carrier section.

Note: the first applicant to apply for access for your carrier National Association of Insurance Commissioners number (NAIC) will be set up as the carrier “administrator” for all future applicants from the same carrier NAIC number. It will be the carrier “administrator” responsibility to approve, deny, or remove as needed, additional users and passwords for access to this site. Once the carrier administrator is established, future applicants to this carrier site associated with the same NAIC number will be forwarded via email to the carrier administrator for approval. The carrier administrator will be able to approve or disapprove each applicant related to the administrator’s NAIC carrier number. The administrator will also be able to view approved users and delete when appropriate. If there are any questions regarding the carrier administrator’s role, call 601-981-2915 or email [email protected]

Carrier NAIC Number: *

Are you willing to assume the Carrier “Administrator” Role per above:

Yes

Carrier Name: *

Carrier Type: *

Carrier Home Office Street Address: *

Carrier Home Office City: *

Carrier Home Office State: *

Carrier Home Office Zip Code: *

Applicant’s Carrier Regional or Field Office City: *

Applicant’s Carrier Regional or Field Office State: *

Applicant’s first name: *

Applicant’s middle initial:

Applicant’s last name: *

Applicant’s phone number: *

Format: xxx-xxx-xxxx

Applicant’s fax number:

Format: xxx-xxx-xxxx

Applicant’s email address: *

A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.

Choose a Username: *

Spaces are allowed; punctuation is not allowed except for periods, hyphens, apostrophes, and underscores.

Choose a Password: *

Provide a password for the new account in both fields. Please make this password at least 6 characters long.

Verify Password: *