Member Website Registration

In order to gain access to our secured Member Resource Center, you must first register for a user name and password.

Please complete the form below to begin the process.

Username*

Your Name*

First Last

Your Phone Number*

Your Email Address*

Are you an agent or broker?*

Yes
No

ENTITIES*

Entity Name	Member Type

Please add an Entity Name for each entry. Member Type options for each entity will specify permissions being requested.
Please select one Member Type from the drop down menu for each entity. Clicking the + icon allows you to add additional entity fields.

Entity Name

Please add an entity name.

Entity Address*

If Agent/Broker, please enter Agent/Broker address.

Street Address Address Line 2 City State ZIP Code

By electing to obtain a user name and password with this application, the member acknowledges that the information and services to be accessed through this web site are provided “as is” and there are no warranties of representation, expressed or implied, as to any information or service provided hereunder, and that the entire risk as to the performance and results achieved thereunder is assumed by the user.

The member is responsible to use reasonable security measures to protect its user name and password and understands and agrees that PennPRIME is not responsible for any unauthorized use of the member’s user name and password.

Signature*

Member Resource Center Website Registration