Register

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View Instructions

Are you registering as a Life Insurance Company?*

Yes
No

Company*

Address*

Address

City*

State*

Zip*

First Name*

Last Name*

Telephone Number*

Extension

FAX Number

E-mail Address*

Password*
Your password must be at least 8 characters long
Your password must utilize at least three out of the following four criteria:

Uppercase characters
Lowercase characters
Numerical characters
Special characters

Re-type Your Password*

Confidentiality of Child Support Information
The remote user, Company Name, and its employees shall use information obtained from the Child Support Lien Network (CSLN) only to the extent necessary for the administration of the child support program. The remote user shall access the web site solely for the intent of reviewing information regarding past due support, provided by the Title IV-D agencies. CSLN shall be utilized for the purpose of paying proceeds from an insurance settlement.
I agree to comply with all applicable state and federal laws relating to confidentiality and privacy, including, but not limited to 42 U.S.C. 654 (26).
I understand any insurer or insurance company, its directors, agents and employers will withhold amounts from payment based upon the latest information supplied by CSLN or the Title IV-D agencies utilizing CSLN. Disbursements will be made in accordance with the instructions provided by CSLN or the Title IV-D agencies. Any insurer or insurance company, its directors, agents and employers shall be in compliance and shall be immune from any liability to the claimant, payee lienholder, or security interest holder for taking such action.
I understand that the employees of the company will have access to personal data described herein and agree not to disclose said information pursuant to both applicable state and federal laws.
I UNDERSTAND THAT TYPING THE DATE, MY NAME AND JOB TITLE AND CLICKING THE "REGISTER" BUTTON ON THIS FORM BINDS ME TO THE SAME EXTENT AS A WRITTEN SIGNATURE.

Name:	SIGNATURENAME	
Date:	SIGNATUREDATE
Title:	CONTACTTITLE
	COMPANYNAME

I UNDERSTAND THAT TYPING THE DATE, MY NAME AND JOB TITLE BELOW AND CLICKING THE "REGISTER" BUTTON ON THIS FORM BINDS ME, MY COMPANY, ITS EMPLOYEES, DIRECTORS, SUBCONTRACTORS AND AGENTS TO THE TERMS AND CONDITIONS OF CSLN'S CONFIDENTIALITY STATEMENT TO THE SAME EXTENT AS A WRITTEN SIGNATURE.

Individual Full Legal Name (signature)*

Date*

Job Title*

Don't fill this in!

Passwords are upper and lower case SenSitiVE!