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Interactive eQuote Request Section

We offer a selection of online forms to help facilitate a speedy quote back to you.

 

INTERACTIVE QUOTE REQUEST FORMS:  (CLICK LINK TO VIEW)

#

Name

Description

Link

1.

AUTO INSURANCE QUOTE

Auto Insurance Quote - Interactive

Auto

2.

HOME INSURANCE QUOTE

Home Insurance Quote - Interactive

Home

3.

BUSINESS INSURANCE QUOTE

Business Insurance Quote - Interactive

Business

 

Applications & Forms

 

We offer a selection of Standardized ( ACORD) Insurance Applications & Forms to help facilitate  speedy quotes and/or underwriting reviews. These applications do not bind any requested coverage as as written notice of approval & acceptance of coverage may only be issued to your be any insurance companies underwriting staff  .  We are authorized to representatives for several leading insurance carriers . ACORD applications are generally accepted by  insurance carrier underwriting departments as these forms have been approved by most State Insurance Regulatory Departments. Customized Business Insurance/ Homeowners / Non-Standard Auto Programs that have been  developed for a Type Specific Risk Groups or Business Classifications by a carrier we represent may be requested by calling us at 1-800-361-8734 or  emailing:  edhemphill@hemphillinsuranceagency.

 

Interactive Fillable PDF Forms 

Adobe PDF Downable Form

   

AUTO RELATED FORMS: (CLICK LINK TO DOWNLOAD ~ VIEW ~ PRINT )

#

Name

Description

 

Download Link

Fillable Link

1.

 ACORD 90TX

Texas Personal Auto Application

 

PDF

PDF Fillable

2.

 ACORD 11

Auto Accident Information Form

 

PDF

PDF Fillable

3.

 ACORD2

Automobile Loss Notice

 

PDF

 

4.

 E.I.A. CHANGE

Coverage Change  Request

   

5.

 DPS  DL-64

Change Address/Updated License

   

6.

 FORM 130U

Motor Vehicle Title Application

   

7.

 VTR-14G

Address Change Vehicle Registration

   

8.

 VTR-60

Replacement License Plate/Sticker

   

9.

 VTR-214

Application For Disabled Person

   

10.

 ACORD 12

Exchange Of Information Form

 

PDF

 

11.

 ACORD 13

Witness Card

 

PDF

 

12.

 TEXAS DPS

New Resident Auto Information

   

13.

 TXDOT

Tips To Prevent Auto Theft

   

 

HOME RELATED FORMS: (CLICK LINK TO DOWNLOAD ~ VIEW ~ PRINT )

#

Name

Description

Download Link

Fillable Link

1.

ACORD 80

Homeowners Application

PDF

PDF Fillable

2.

ACORD 84

Dwelling Fire Application

PDF

 

3.

ACORD1

Property Loss Notice

PDF

PDF Fillable

4.

ACORD 42

Residential Property Replacement Cost

PDF

PDF Fillable

5.

ACORD 18

Jewelry Appraisal And Claim Evaluation

 

6.

ACORD 67TX

Homeowners Personal Property Supplement

PDF

 

7.

BAD RO23A

Residential Homestead Exemption Application

 

8.

E.I.A. CHANGE

E.I.A. Coverages Change Form

 

9.

TEXAS FAIR PLAN

Description Of Coverages

 

10.

TEXAS FAIR PLAN

Frequently Asked Questions

 

11.

TX  50-135

Application For Disabled Veteran Exemption

 

12.

ACORD 64TX

Application For Windstorm And Hail Insurance

PDF

 

13.

ACORD 69TX

TX Special Mobile Home Windstorm/Hail App

PDF

 

 

BUSINESS RELATED FORMS: (CLICK LINK TO DOWNLOAD ~ VIEW ~ PRINT )

#

Name

Description

Download Link

Fillable Link

1.

ACORD 125

Commercial Insurance Application

PDF

 

2.

ACORD 140

Property Section

PDF

 

3.

ACORD 126

Commercial General Liability

PDF

 

4.

ACORD 137TX

Texas Commercial Auto

PDF

 

5.

ACORD 163

Commercial Auto Driver Information

PDF

PDF Fillable

6.

ACORD 138TX

Texas Garage and Dealers

PDF

 

7.

ACORD 175

Commercial Policy Change Request

PDF

PDF Fillable

8.

ACORD 28

Evidence of Commercial Insurance

PDF

 

9.

ACORD 3

Liability Notice of Claim

PDF

PDF Fillable

10.

ACORD 130

Workers Compensation Application

PDF

PDF Fillable
 11.  ACORD 4  Workers Compensation -                  1st Report of Injury or Illness

PDF

PDF Fillable
 12.  FSS-4  Employer Federal Tax Id - Application

PDF

 

 

OTHER FORMS: (CLICK LINK TO DOWNLOAD ~ VIEW ~ PRINT )

#

Name

Description

Download Link

Fillable Link

1.

ACORD 82

Watercraft Application

PDF

 

2.

ACORD 83

Personal Umbrella Application

PDF

 

3.

ACORD 35

Cancellation Request/Policy Release

PDF

PDF Fillable
 4.  ACORD 36  Agent Of Record Change

PDF

 

 

Interactive Fillable MSWORD.DOC Forms 

Interactive Fillable PDF Forms 

Adobe PDF Downable Form

WORKERS COMPENSATION APPLICATIONS &  RELATED FORMS: (CLICK LINK TO DOWNLOAD ~ VIEW ~ PRINT )

#

Name

Description

Fillable MSWORD DOC

Download  PDF

 Link

Fillable PDF

 

 Link

1.

ACORD 130

Workers Compensation Application

PDF

PDF Fillable
 2.  ACORD 4  Workers Compensation - First Report of Injury or Illness

PDF

PDF Fillable

3.

EEProvForm.doc

Texas Mutual - Employee Provider Form EP-1a

 

 

4.

5606Questions.doc

Texas Mutual - Executive Supervisor Questionnaire (5606)

PDF

 

5.

IndContractorQuestions.doc

Texas Mutual - Independent Contractor Questionnaire

PDF

 

6.

Peo_newclient.doc 

Texas Mutual - Professional Employer Organization New Client

PDF

 

7.

Peo_questionnaire04.doc

Texas Mutual - Professional Employer Organization Questionnaire

PDF

 

8.

StartSupAp05.doc

Texas Mutual - Start Program Supplemental Application

PDF

 

9.

AircraftSuppApp.doc

 Texas Mutual - Supplemental Application Aircraft Operations

PDF

 

10.

LHWapp.doc

 Texas Mutual - Supplemental Application Longshore and Harbor Act

PDF

 

11.

Jonesapp.doc

 Texas Mutual - Supplemental Application Jones Act

PDF

 

12.

OCSapp.docotherstates.doc

 Texas Mutual - Supplemental Application Outer Continental Shelf

PDF

 

13.

Otherstates.doc

 Texas Mutual - Supplemental Application Other States Endorsement

PDF

 
 14.  Supedw.doc  Texas Mutual - Supplemental Employee Data Worksheet

PDF

 
 15.  ConcEE-Tempsvc.doc  Texas Mutual - Supplemental Employee Worksheet - Temp Services

PDF

 
 16.  Truck_Industry_Quest.docT  Texas Mutual - Trucking Industry Questionnaire

PDF

 
 17.  Dwc81.pdf  TDIl - DWC-81, Agreement Between General Contractor and Subcontractor to Provide Workers’ Compensation Insurance     PDF Fillable
 18.  Dwc82.pdf TDI - DWC-82, Agreement Between Motor Carrier and Owner Operator to Provide Workers’ Compensation Insurance Coverage / Agreement to Require Owner Operator to Act as Employer     PDF Fillable
 19.  Dwc83.pdf  TDI - DWC-83, Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers / Agreement to Establish Employer-Employee Relationship for Certain Building and Construction Workers     PDF Fillable
 20.  Dwc84.pdf  TDI - DWC-84, Exception to Application of Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers  

 

  PDF Fillable
 21.  Dwc85.pdf TDI - DWC-85, Agreement Between General Contractor and Subcontractor to Establish Independent Relationship     PDF Fillable
 22.  WC-RFI.doc  TDI - Workers' Compensation- Request for Information

PDF