Fillable Account Updates (IntelliCorp)

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Account Updates (IntelliCorp)

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The Account Updates (IntelliCorp) form is 2 pages long and contains:

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  • 47 other fields

Country of origin: US
File type: PDF

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Account Information Change Form
FORM MUST BE COMPLETED, SIGNED AND DATED
REPLY OR RETURN VIA EMAIL OR FAX TO
CREDENTIALING@INTELLICORP.NET OR VIA FAX AT 216-450-5105
Company Name: Phone:
Physical Address: Fax:
Billing Address: Email:
City: State: Zip:
Primary Contact: Federal Tax ID:
Change information on my account FROM the following
(Please complete with previous information):
Box 1
No:
Has Ownership Changed: Yes:
No:
New Login Needed for Contact Yes:
Company Name: Phone:
Physical Address: Fax:
Billing Address: Email:
City: State: Zip:
Primary Contact: Federal Tax ID:
Primary Contact Email Address (If New):
Box 2
Page 1 of 2
All information must be completed and signed by an authorized agent, principal or officer of the company
ACCOUNT ID Product Access: MVRs Y N
Credit Reports Y N
Drug Screening Y N
Account Updates
* Box 1 MUST be filled out completely. FED TAX IDs ARE REQUIRED FOR BOXES 1 & 2.
Insert N/A for fields intentionally left blank *
Note: If there is a change in any information on your IntelliCorp account (business name, address, phone number, e-mail address,
etc.) AND you have access to MVRs, Drug Screening, or CREDIT REPORTS, new service agreements and/or additional steps may be
needed.
Version 5/2019
Account Information Change Form
FORM MUST BE COMPLETED, SIGNED AND DATED
REPLY OR RETURN VIA EMAIL OR FAX TO
CREDENTIALING@INTELLICORP.NET OR VIA FAX AT 216-450-5105
Page 2 of 2
Billing Updates IntelliCorp Account ID:
Website Access
You are signing this document electronically and consenting to the
legally binding terms and conditions. You acknowledge and agree that
your electronic signature is the legal equivalent to your handwritten
signature for the purposes of validity, enforceability and admissibility.
Date: Title:
Disable Users:
No:
E-mail Address: Administrator Access: Yes:
Name: Telephone #:
No:
E-mail Address: Administrator Access: Yes:
Name: Telephone #:
No:
E-mail Address: Administrator Access: Yes:
Add Users:
Please list new users requiring access to your account via the IntelliCorp web-site for submitting and viewing searches.
Each authorized person will be assigned a unique User ID and Password. For security purposes, User ID’s and
Passwords are confidential and should not be shared.
Name: Telephone #:
No
:
No:
Is login only to view and pay invoices? Yes:
NEW Billing Contact Name: NEW Billing Telephone #:
NEW Billing Address:
NEW Billing Email:
OR Will login be used to submit/view searches? Yes:
No:
X
No:
NEW Login Needed for Billing Contact? Yes:
Signature of Owner/Officer or Legally Authorized Representatives
Version 5/2019
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Account Updates (IntelliCorp)

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Completed 29 July 2020

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