CIC - Commercial Insurance Center

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Full Name:
Telephone:
Email:
Type of Insurance:	Personal Business
Insurance Needed

Additional Comments:

Workers Compensation Quote

Workers compensation insurance protects an employer from liability for an accident involving an employee. The insurance coverage pays benefits to your employees if they are injured on the job. It will cover their medical bills, a portion of lost wages, vocational rehabilitation, and death benefits. The coverage amount is established by state law and benefits don’t vary from company to company within the same state.

Texas workers compensation insurance covers all the employees of the business. Special provisions must be made if an employee works out of state. It may cover the business owner if the business is a corporation and the owner is actively involved in the business.

Texas Business Information

Business Name:
Premises Address:
City:
State:
Zip Code:
Contact Name:
Phone:	.Cel.: .Fax:
Years in Business:
Email Address: (Required)

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About Your Texas Business:

Federal Employer's ID #:
Description of Operations or SIC code:
# of full-time employees:	# of part-time employees:
# of locations:	Estimated Annual Payroll: $

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Select all that apply to your Texas business:

Operate or lease aircraft/watercraft	Work Underground
Work above 15 feet	Require out of state travel
Use Subcontractors	Delivery Service
Pre-employment physicals	Offer safety incentive programs
Work on vessels, docks, or bridges over water	Store, treat, dispose, or transport hazardour waste
Other

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Recent Insurance Information:

Current Insurance Company:
Policy #:
Expiration Date:	(mm/dd/yyyy)
Losses past 3 years:
Description of losses or loss runs:

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What types of coverages do you currently have:

Commercial Auto	Commercial Liability
Commercial Property	Workers Comp
Group Health	Group Life
Group Disability	Group Long Term Care
Other

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Texas Employee Information:

Employee	Job Type	Yearly Payroll Estimate
1		$
2		$
3		$
4		$
5		$

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Officers / Partners / Owners Information:

Principal	Name	Title	Include
1
2
3


Additional Information or Comments:

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Click on the "Submit Quote Information" button below to send your
Texas Workers Compensation Insurance quote request.**

“Information received from this Texas Business Liability Insurance quote request form sent to our company, will be for our use only and will not be sold, given to or distributed to any other parties.”