QuickComp PH Access Request

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QuickComp Access Request for Claim Information Center

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*	Insured/Policy Holder Name:
	If you have multiple policy numbers, please list all that apply with commas separating them. If you do not know your policy number, leave it blank and someone from MEMIC will contact you when this form is received.
	Policy Numbers:
*	Agency Name:
	Who will be the company contact for the Claim Information Center (QuickComp)?
*	First Name:
	Middle Initial:
*	Last Name:
*	Title:
*	Mailing Street Address 1:
	Mailing Street Address 2:
*	City:
*	State:
*	Zip code:
	Email:
*	Telephone #:
	Fax #:
	Access Agreement: By signing this form you agree that your ability to access file records pertaining to individual workers compensation claims is subject to the following terms and conditions. All records provided to you are used by MEMIC for the limited purpose of processing claims for workers’ compensation benefits in accordance with the applicable state and federal laws and for no other purpose. You agree that use of these records by you will be limited to lawful purposes under state and Federal laws and for no other purpose. You agree to release, hold harmless and indemnify MEMIC for any claim asserted against MEMIC for improper use of said file records. You agree that you will not allow any medical records contained in the MEMIC file to be placed in an employee’s personnel file consistent with the Americans with Disabilities Act and any state’s Human Rights Act and that you will maintain such records in a separate and secure location. Further, by using MEMIC’s on-line service you assume all risks associated with the use of this site, including any risk to your computer, software or data being damaged by any virus, software, or any other file which might be transmitted or activated via this connection or your access to it. MEMIC shall not be liable for any direct, indirect, punitive, special, incidental, or consequential damages, including, without limitation, lost revenues, or lost profits, arising out of or in any way connected with the use or misuse of information or lack of information contained within these files.
*	Do you agree to Above Access Agreement? Yes No