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SUBMIT INFORMATION FOR A QUOTE

Here is your opportunity to send information for a quote or request additional information. Please enter the information below and we will review and respond directly to you.

We look forward to providing you with the best service available. Please make sure you provide your name, phone number and the best time to be reached. A brief description of your business can help jump start this process also. The more information the better.

There is no cost or obligation on your part by completing this form, it only helps begin the process. All information is held in the strictest of confidence.

Sales Agent / Broker *
Contact Details
Client Company Name  * DBA  *
Website Email ID  *
Telephone  * Fax  *
Physical Address  * City  *
  State
  Zip  *

   Tick if Mailing Address is same as Physical Address.

Mailing Address  * City  *
  State
  Zip  *
Company Details
Type Of Business  * Years In Business  *
Describe Business Oprations Federal Tax I.D. No.
State Unemployment I.D.No. State Unemployment Tax Rate (SUTA)  *
List Date you want worker's comp. insurance to start SIC (Standard Inndustry Classifification) Code
(Please allow sufficient time for processing of this application) NAICS (North American Industrial Classification System) Code
Will we be providing worker's comp. for all of your employees ?  
Employee classification data(Attached sheet for additional NCCI Codes) NCC ID #
NCCI/TX Code# of EmpStateDueties
(Describe in detail)		Annual Payroll 
Identify number of employees outside of Texas and in what states?
EE's States
Supporting Documents
Title
Select File
 Valid file format(.pdf,.doc,.xls,.txt,.jpeg,.jpg, .bmp, .png, .gif)
Title
Select File
 Valid file format(.pdf,.doc,.xls,.txt,.jpeg,.jpg,.bmp,.png,.gif)
Title
Select File
 Valid file format(.pdf,.doc,.xls,.txt,.jpeg,.jpg, .bmp, .png, .gif)
It will help us give you an accurate comparison quote if we are able to see what your paying now. If possible please include your current workers compensation declarations page and your last Effective Tax rate from your previous 941.
 
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