eSelect® Username & Password Request Form

New Userâ€™s First and Last Name:

New Userâ€™s Email Address:

New User Access:

Requestor Name:

Requestor Email:

Agency Name:

Agency Code:

User Phone:

Access to eSelect:

Yes No

Selectiveâ€™s Agent Portal

Is this user a third party vendor?:

Yes No

Third-party is a service provider who is not directly controlled by the agency

Access to CLAS:

Yes No

Commercial Lines Rating System

Access to PLUS:

Yes No

Personal Lines Rating System

Access to Billing System:

Yes No

Expanded Billing System Access (Commission/Agency Statements, Pay Agency Statements, Register Banking):

Yes No

Access to Flood System:

Yes No

Flood Rating System

Comments:

Security Code:

* indicates required field

Submit: