Insured Portal Enrollment Form

Falls Lake Insurance Companies Workers' Compensation

Insured Portal Enrollment Form
Please complete the fields below to create your portal log on for your Workers’ Compensation insurance policy with Stonewood Insurance Company or Falls Lake National Insurance Company. Accounts will be created within 24-48 hours of receipt.
Policy Number
WC
Insured Name
DBA

Portal User Account Information
Name

First Name Last Name
Title
Phone Number

Area Code Phone Number
Email

Confirmation Email example@example.com
Admin Access to add and delete users:

Yes No
- Please be advised that portal users will have access to any bank account information and claims information available on the portal.
- By electing to enroll in the Falls Lake/Stonewood Insured Portal you will now receive your billing statements at the email address provided above.
- Once portal enrollment is complete you will no longer receive a paper billing statement in the mail. Your billing statements will be emailed to you every time a statement is generated.
Signature of Insured Owner/Officer/LLC Member REQUIRED
Officer Name

First Name Last Name
Signature

Clear
Title
Date

Month Day Year
Date
Should be Empty:

Falls Lake Insurance Companies Workers' Compensation