Insurance Specialists Workers Comp - Save $$ on CRNA Malpractice, Professional & General Liability, Workers Comp & Alternatives, Group Health and Life!

Please fill out the form below. ( * Required Fields)

* Business Name

*Contact Name

* Mailing Address

*Physical Address

* Email Address

* City

* State

* Zip Code

*Years In Business

* Phone #

Cell #

Fax #

*Type of Business

*Federal Tax ID # or SS#

Information on completing the information below:

Workers comp is based on the payroll. Payroll needs to be broken out by employee classification an if they are part-time or full-time. If you dont have part-time employees in a certain classification put "NA" for "Not Applicable" in the box.

Categories, Duties, & Classifications	# of Employees		*Annual Payroll Part-Time	*Annual Payroll Full-Time	*Detailed Job Description
Categories, Duties, & Classifications	Part Time	Full Time	*Annual Payroll Part-Time	*Annual Payroll Full-Time	*Detailed Job Description

Do you currently have coverage?

*Describe all losses in the last 3 years

*Owner's names and percent of ownership:

Nature of your business / Description of operations

*Are you aware that workers compensation is not mandatory in Texas?

*Is your business required to carry workers comp?

*If you are not required to carry workers compensation, would you like free information on a workers comp alternative that could save you as much as 50% on your premium?