Workers Compensation Applications & Forms

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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

Interactive Fillable MSWORD.DOC Forms

Interactive Fillable PDF Forms

Adobe PDF Downable Form

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 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 have been developed for Specific Industry Purchasing Groups or Other Specific Business Classifications by carriers we represent ; for more information call us at 1-800-361-8734 or emailing: edhemphill@hemphillinsuranceagency.

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
2.	ACORD 4	Workers Compensation - First Report of Injury or Illness
3.	EEProvForm.doc	Texas Mutual - Employee Provider Form EP-1a
4.	5606Questions.doc	Texas Mutual - Executive Supervisor Questionnaire (5606)
5.	IndContractorQuestions.doc	Texas Mutual - Independent Contractor Questionnaire
6.	Peo_newclient.doc	Texas Mutual - Professional Employer Organization New Client
7.	Peo_questionnaire04.doc	Texas Mutual - Professional Employer Organization Questionnaire
8.	StartSupAp05.doc	Texas Mutual - Start Program Supplemental Application
9.	AircraftSuppApp.doc	Texas Mutual - Supplemental Application Aircraft Operations
10.	LHWapp.doc	Texas Mutual - Supplemental Application Longshore and Harbor Act
11.	Jonesapp.doc	Texas Mutual - Supplemental Application Jones Act
12.	OCSapp.docotherstates.doc	Texas Mutual - Supplemental Application Outer Continental Shelf
13.	Otherstates.doc	Texas Mutual - Supplemental Application Other States Endorsement
14.	Supedw.doc	Texas Mutual - Supplemental Employee Data Worksheet
15.	ConcEE-Tempsvc.doc	Texas Mutual - Supplemental Employee Worksheet - Texas Department Of InsuranceTemp Services
16.	Truck_Industry_Quest.docT	Texas Mutual - Trucking Industry Questionnaire
17.	Dwc81.pdf	Texas Department Of Insurance - DWC-81, Agreement Between General Contractor and Subcontractor to Provide Workers’ Compensation Insurance
18.	Dwc82.pdf	Texas Department Of Insurance - DWC-82, Agreement Between Motor Carrier and Owner Operator to Provide Workers’ Compensation Insurance Coverage / Agreement to Require Owner Operator to Act as Employer
19.	Dwc83.pdf	Texas Department Of Insurance - 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
20.	Dwc84.pdf	- DWC-84, Exception to Application of Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers
21.	Dwc85.pdf	Texas Department Of Insurance- DWC-85, Agreement Between General Contractor and Subcontractor to Establish Independent Relationship
22.	WC-RFI.doc	Texas Department Of Insurance- Workers' Compensation- Request for Information