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Workers Comp Insurance (Also use for workers comp alternatives)

Name of Company

Contact Person

First     Last  

Contact Number (with area code)

Fax Number (with area code)

Address

Street  

Suite Number  

City     St    Zip 

Email Address *

Web Address

SBCIA.com, Guiding your business in the right direction.

Who Referred You To Our Site?

If you selected Agent or Other, please indicate who

If you selected Search Engine, please indicate which one

SBCIA.com, Guiding your business in the right direction.

Nature of Business (please provide a detailed description)

Federal Employer ID#

Years in Business

Insurance History

Present Insurance Company

Loss History

Workers Comp and Alternatives

Job Classification

Number of employees with this classification

Part-time/Full-time

Annual Payroll

   

1099

W2

  

$

$

$

$

$

$

$

$

$

$

Name of Owner / Officer

Description of Duties

Include or Exclude

For Additional Classifications

Additional Questions or Comments

      
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Southwest Business Insurance Agency, Inc. specializes in business insurance, financial and estate planning in Texas. sbcia.com is a product of Southwest Business Insurance Agency, Inc. Copyright 2002