California Joint Powers Insurance Authority (CJPIA) Member - Embark Safety (MVR Monitoring) Enrollment Form

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Embark Safety Enrollment Form

Welcome aboard, CJPIA Members! We’re happy to partner with you and hope you find our service easy to use. To get you enrolled in the program, it is important we gather this information from you. Should you have any questions, please reach out to your Customer Success Manager at mona.eskariyat@embarksafety.com.
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Who is your California JPIA Regional Risk Manager?* This field is required.
Melaina Francis
Tim Karcz
Lucy Gonzalez
Alex Mellor
Maria Galvan
Tony Leite
Toni Consolo
Don't Know
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What is the name of your agency?* This field is required.
Agoura Hills
Agoura Hills/Calabasas
Community Center
Alhambra
Aliso Viejo
Apple Valley
Area E Disaster Management
Arroyo Grande
Artesia
Atascadero
Azusa
Bell Gardens
Bellflower
Big Bear City Community Services District
Big Bear Fire Authority
Big Bear Lake
Bishop
Black Gold
Cooperative Library System
Bradbury
Brawley
Buellton
Calabasas
Camarillo
Carpinteria
Cerritos
Chino Hills
Claremont
Coachella Valley
Association of Governments
Coachella Valley
Conservation Commission
Coastal Animal Services Authority
Commerce
Dana Point
Desert Recreation District
Diamond Bar
Duarte
Eastern Sierra
Transit Authority
El Centro
Fillmore
Gateway Cities
Council of Governments
Goleta
Grand Terrace
Grover Beach
Guadalupe
Hawaiian Gardens
Hemet
Hidden Hills
Imperial
Indian Wells
Indio
Irwindale
La Cañada Flintridge
La Habra Heights
LA IMPACT
La Mirada
La Palma
La Puente
La Quinta
La Verne
Laguna Niguel
Laguna Woods
Lake Elsinore
Lake Forest
Lakewood
LA-RICS
Lawndale
Lemon Grove
Loma Linda
Lomita
Malibu
Mammoth Lakes
Midpeninsula Regional
Open Space District
Mission Viejo
Monrovia
Monterey Peninsula
Regional Park District
Moorpark
Morro Bay
Mountain Area
Regional Transit Authority
Needles
Norwalk
Ojai
Orange County
Council of Governments
Pacific Grove
Palm Desert
Palos Verdes Estates
Palos Verdes Peninsula
Transit Authority
Paramount
Paso Robles
Pismo Beach
Pomona Valley
Transportation Authority
Port Hueneme
Poway
Rancho Palos Verdes
Rolling Hills
Rolling Hills Estates
Rosemead
Rossmoor Community Services District
San Clemente
San Dimas
San Gabriel
San Juan Capistrano
San Luis Obispo
San Marcos
San Marino
Santa Clarita
Santa Fe Springs
Santa Paula
Seal Beach
Seaside
Seaside County Sanitation District
Signal Hill
Solvang
South El Monte
Southeast Area
Animal Control Authority
Southern California
Association of Governments
Stanton
Temple City
Ventura Port District
Villa Park
Vista
Walnut
West Cities Police
Communications Center
West Covina
West Hollywood
Westlake Village
Other
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Other:
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What is your name?* This field is required.
First Name
Last Name
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What is your email?* This field is required.
example@example.com
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Phone Number * This field is required.
Area Code
Phone Number
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Is your agency currently enrolled in the DMV Employer Pull Notice (EPN) Program?* This field is required.
Yes
No
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Is your agency self-managing your account or are they utilizing an EPN agent?
EPN Agent
Self Managing
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How many users will your agency need?* This field is required.
1
2
3
4+
Should be Empty: