Once you complete the following questionnaire, your shop contact information will be added to the Provider database.
An eDirectGlass representative may call you to verify some or all of the information for security purposes.
 

Contact Information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail
URL

Trading Partner Information:

Total # of retail locations:               # of locations you send insurance bills from:

Average # of monthly invoices:              Average # of direct bill invoices per month:

Do you currently bill through the networks? Yes No
If 'Yes', who?

Do you bill insurance company agents directly? Yes No
If yes, what is the dollar limit of your agent’s draft authority?

Do you bill any insurance companies directly (not agents)? Yes No

         Technology Information:

Do you use any Point of Sale software? Yes No
If yes, which Point of Sale software(s) do you use?

Datatranz  IBS/Elmo  GTS  Mainstreet  Mitchell
Quest  Other

Do you use a fax machine to submit invoices? Yes No

Which computer do you have?

Pentium  Pentium 2  Pentium 3  Pentium 4  Other

Does your computer have a modem? Yes No

Do you have Internet access? Yes No
If yes, who is your Internet Service Provider?

Is your Internet Access Broadband or Dial-up?  Broadband (128K or higher)   Dial-up

Do you have a separate, dedicated phone line for Internet or fax use? Yes No

Do you own a mobile phone with Internet access? Yes No