Sign Up with HMS

1. Workers' Compensation Risk / Policy #:
2. Company Name:
3. DBA (If Applicable):
4. Number of Employees:
5. County of Operation: Select from list Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Green Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbuil Tuscarawas Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot

1. Address:
2. City:
3. State:
4. Zip Code:

1. Contact name:
2. Contact title:
3. Phone number w/ extension:
4. Fax number:
5. E-mail Address:

1. Name of MCO Selected: Health Management Solutions, Inc.
2. MCO Number: 10006

Let us know your human by solving this math problem.