Community Insurance Advisors - A Different Way of Doing Insurance
P:972-758-9300 | F:972-758-9355

Worker's Compensation

Worker's Compensation provides medical care for employees who are injured in the course of employment, in exchange for mandatory relinquishment of the employee's right to sue his or her employer. Carriers work with employers to identify and manage against perils that may disrupt the continuity of the workplace. Fill Out A Worker's Compensation Application:

Section I - Client Business / Information

Name: *

Phone: *

Email: *

Confirm Email: *

Mailing Address *

Location Address: *

FEIN: *

Following forms are optional, Please fill in if you would like to provide more information.

Section II - Policy Information

Employee #1 Category:

# Full-Time

# Part-Time

Estimated Annual Payroll

Employee #2 Category:

# Full-Time

# Part-Time

Estimated Annual Payroll

Employee #3 Category:

# Full-Time

# Part-Time

Estimated Annual Payroll

# Part-Time

Employee #4 Category:

# Full-Time

Estimated Annual Payroll

Employee #5 Category:

# Part-Time

# Full-Time

Estimated Annual Payroll

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Community Insurance Advisors - A Different Way of Doing InsuranceP:972-758-9300 | F:972-758-9355

Worker's Compensation

Worker's Compensation Application

Section I - Client Business / Information

Section II - Policy Information

TDI License Numbers

Community Insurance Advisors - A Different Way of Doing Insurance
P:972-758-9300 | F:972-758-9355