Products & ServicesOccupational Accident

Workers Comp rates are on the rise.

If you are not familiar with this market, call today and talk with our specialist. This product is unique to Texas agents and Texas groups only. For more information talk to:

Russell Bosworth
800-882-1488 or 972-701-1200

The Texas Department of Insurance - Division of Workers' Compensation (TDI-DWC) recently revised forms that nonsubscribers are required to file with the state. One of these forms, The Employer Notice of No Coverage or Termination of Coverage, more commonly known as the DWC005, is a dual purpose form that employers must utilize to report their nonsubscriber status when they elect to become a nonsubscriber and each year they continue to operate as a Texas nonsubscriber.


Employer Notice of No Coverage or Termination of Coverage.pdf (904.36 KB)


Fax a Quote Request Form.pdf (179.37 KB)
Request For Certificate of Insurance.pdf (117.51 KB)

ACE American

ACE American Agent Lic.pdf (3.47 MB)
ACE American Brochure.pdf (2.58 MB)
ACE American PEI - All New Business Form.pdf (116.92 KB)

Pan-American Life

Amendment for Employer Indemnity Coverage.pdf (425.32 KB)
GWI - Occ Acc Claims Guide FINAL 6-1-11.pdf (858.55 KB)
Occ Acc Presentation Folder 01-24-2011.pdf (178.41 KB)
Occ Acc Presentation Insert BROKER Info updated 06-2012.pdf (224.28 KB)
Occ Acc Presentation Insert EMPLOYER Info UPDATED 4-2010.pdf (118.68 KB)
Occupational Accident Policy.pdf (1.92 MB)
Pan American - Pay on Behalf Application aug 2011 (b).pdf (1.05 MB)
Pan-American Agent Licensing (12-2015).pdf (285.52 KB)
Pan-American Agent Licensing Paper App (12-2015).pdf (268.08 KB)
FCRA Summary and Authorization - Required for Licensing.pdf (331.53 KB)

Fidelity Security

Fidelity Security Brochure.pdf (756.63 KB)
Fidelity Security Contract.pdf (1.37 MB)
Fidelty Security Application.pdf (282.88 KB)

Independence American Insurance

IAIC Agent Lic 6-16-2015.pdf (708.49 KB)
IAIC Applications with Legal 6-1-15.pdf (360.13 KB)
IAIC Applications without Legal.pdf (145.19 KB)

Standard Security Life Insurance Company

GAPP1v13.pdf (1.57 MB)
GAPP1v13 Rates 03 14 14 v6b.pdf (814.63 KB)
GAPP2v12.pdf (1.17 MB)
SSL Appointment.pdf (654.65 KB)
SSL CLAIM FORM.pdf (533.43 KB)


American Hallmark Admitted Applications.pdf (245.72 KB)
Contract Labor Census Sheet.pdf (109.13 KB)
Hallmark Producer Agreement.pdf (962.91 KB)

Truckers Accident Protection Plans

TAPP v10.pdf (1.5 MB)
SSL Appointment.pdf (654.65 KB)

Have Questions? Call +1(800)882-1488

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