Company Information

    Register your business to create an Employee Benefit Program account.

    Registration allows you to access the Program dashboard and include your company branding. If you have not yet discussed an Employee Benefit Program with us, call or email 214-673-0065 or support@emergencycontactdata.com.

    Begin by completing the information below

     

    • ORGANIZATION NAME*

    • ADMIN FIRST NAME*

    • ADMIN LAST NAME*

    • ADMIN TITLE*

    • ADMIN EMAIL*

    • VERIFY ADMIN EMAIL*

    • PASSWORD*

       

    • VERIFY PASSWORD*

      • Enter 8 to 11 alpha/numeric upper & lower case characters

    • ALTERNATE EMAIL 

    •   My organization has completed a signed-agreement governing the distribution of the Emergency Contact Data Service. This registration enables access to the program dashboard to monitor employee participation, expenditures and company invoicing and payments.*

    •  

    • ADDRESS 1*

    • ADDRESS 2 

    • ADDRESS 3 

    • CITY*

    • ST/PROV*

    • ZIP/CODE*

    • COUNTRY*

    • PRIMARY PHONE*

         

    • EXT. 

    • ALTERNATE PHONE 

         

    • EXT. 

    • FAX 

         

    • INT’L DIALING CODE*

    • APPROX. NUMBER
      OF EMPLOYEES 

    • WILL EMPLOYEES RESIDING
      OUTSIDE OF THE U.S. BE INCLUDED?  YES

    • COMMENT: 

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