Contact Name:

Business Name:

Address:

City:

Zip Code:

Phone Number:

Email Address:

Best Time  to Call:

AM

PM

Do you have insurance now?

Present insurance company:

My policy expires:

Yes

No

Business Type (check one):

If a Corporation, should officers be covered?

Sole Proprietor

Corporation

YES

NO

Do You Have Current Loss Runs?

Number of Locations:

Any Locations Outside of Texas?

YES

NO

YES

NO

Number of Full Time Employees:

Number of Part Time Employees:

Employees Covered by Health Insurance?

YES

NO

Classification Code:

Annual Payroll:

Classification Code:

Annual Payroll:

Classification Code:

Annual Payroll:

Classification Code:

Annual Payroll:

Experience Modification:

Comments or Questions:

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