SAM registration form

Agency information

Agency name*

Agency number*

Address*

Street Address Address Line 2 City State ZIP Code

SAM user information

Name*

Title

Work Address (if different from above)

Street Address Address Line 2 City State ZIP Code

Phone number*

Fax number

Email*

Location information

Does the agency have multiple locations?*

Yes
No

Does this SAM user account need access to all locations?

Yes
No

Specific locations only

If this SAM user account is for specific locations only, list them here.

Access to confidential information

SAM users are able to access confidential information about policyholders and their claims.

Agency administrator

Check this box if you are the authorized administrator for your agency to request administrator privileges

SAM allows agency administrators to maintain user accounts for their agency. Specifically, an agency administrator can: create a user, change user passwords and other information, activate a user, inactivate a user, select active locations for a user, view obsolete locations, view SAM authority. Prior to enabling this capability, SFM staff will verify your agency administrator status with the agency principal below.

Agency principal information

Note that the registration process may be delayed if we are unable to contact this individual for authorization.

Principal name*

Principal title*

Phone number*

Fax number

Email*

SAM terms and conditions

By registering for SAM, you agree to the following terms and conditions:
                        
1. SAM is a service provided by SFM Mutual Insurance Company (SFM) to its customers at its sole discretion. SFM is under no obligation to provide access to SAM and may limit or terminate your access at any time for any reason.

2. You are responsible for protecting the privacy of your user name(s) and password(s) and for protecting the confidentiality or privacy of any information obtained using SAM. You agree to exercise due care to prevent unauthorized employees within your organization and outside third parties from gaining access to SAM. SFM has no liability whatsoever for the protection or privacy of your user name(s) and password(s) and shall not be liable for any consequential, incidental or special damages (including, without limitation, loss of business or profits) whether based on breach of contract, breach of warranty, negligence or otherwise, with respect to the privacy of your user name(s) and password(s).

3. The workings of SAM represent a trade secret and intellectual property of SFM. You may not disclose information about SAM (except for information that is already public), or demonstrate SAM, to anyone outside your organization without the written permission of SFM.

4. Much of the information and many of the resources contained within SAM are private, confidential and/or proprietary. You acknowledge that your user(s) may have access to sensitive and private medical information about claimants and to other confidential and/or proprietary information within SAM, and you agree that such information is not for secondary release or disclosure, which release or disclosure is strictly prohibited. You agree that if any such private, confidential or proprietary information is released or disclosed by you (including your user(s)), you are responsible for any damages claimed to arise out of such release or disclosure by any aggrieved party and/or by SFM.

5. SFM will take reasonable measures to keep third parties from unauthorized access to information submitted by you and to reports requested by you that are contained in or derived from SAM; however, SFM does not guarantee that third parties will not have access to any information, comments or materials that you submit to SFM through the SFM website.

6. SFM specifically disclaims any liability with respect to SAM and its other Web-based services. SFM shall not be liable for any damages, including, but not limited to, direct, indirect, incidental, special or consequential damages, arising from the use of SAM or any of the materials or information contained therein, or arising from any third parties' access to information submitted by you to SFM, or arising from your disclosure of confidential or private information to unauthorized persons.

7. The resources contained within SAM, and the source code used to produce them, are copyrighted by SFM. These terms and conditions and your use of SAM shall be governed in all respects by the laws of the State of Minnesota, except where such law is specifically pre-empted by federal law.

8. Access to SAM indicates the recipient acknowledges that it has the capacity or capability to retrieve the electronic records of question as prescribed by SFM.

I accept these terms and conditions*

I accept these terms and conditions

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Policyholders

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