ACCIDENT INSURANCE SERVICES, INC.

800 880 2515

972 788 5108 FAX

Type of Proposal Requested:

Occupational Accident Only

Occupational Accident w/Legal

Employer's Excess Indemnity

Applicant Information

Requested Effective Date

Applicant Name Email Address

Address City Zip Nature of Business

Number of Years in Business Tax ID # Date of worker's comp coverage rejection

Has worker's comp or occupational accident coverage ever been cancelled, refused or non-renewed?     N Y

If Yes, please explain

Business Type:     Corporation Partnership Other:

Is applicant subject to LPG or TxDOT Regulations?     N Y Within what radius does applicant haul?

Does applicant handle, store, or engage in transport of hazardous materials (including but not limited to explosive, caustic, poisonous, or flammable materials)?     N Y

If Yes, please explain:

Please specify commodities hauled:

What percentage of loads are manually loaded or unloaded? % Loaded % Unloaded

Does applicant perform any work at heights over 24 ft.?     N Y

If Yes, please explain:

Are Owners, Officers or Partners to be covered?     N Y Are any affiliate companies to be covered?     N Y

If Yes, please provide Legal Name, Address, and number of employees at each location:

Total Number of Employees Total Payroll $ Waiver of Subrogation?     N Y

Current Worker's Comp or Accident Premium $ Occupational Disease & Cumulative Trauma?     N Y

Benefits to be Quoted:   Limits Vary by Product. Please Call For Other Options.

Benefit Period:   52 wks 116 wks 156 wks   Weekly Income (75% up to $700) Waiting Period days

Please submit 3 years (hard copy) currently valued loss history;   Valuation Date of loss information:

Do you want EL Coverage? N Y

Agent: Phone:

Address: FAX: