	713.527.0444 :: 1.888.266.2680 \| 3131 West Alabama, 4th Floor \| Houston, Texas 77098

Worker's Compensation Insurance

Worker compensation Workers' Compensation Programs protect your employees if they become injured on the job. Injured workers are covered for required medical treatment and loss of time from work. Dean & Draper will work together with you to make sure that you have the appropriate coverage to meet your company's needs.

Please call 1.888.266.0444 or 713.527.0444 or just fill out and submit the form below.

* Denotes a Required Field

Tell Us About Yourself

How did you hear about us:*

Other:

Salutation

First Name*

Last Name*

Company

Address*

Address 2

City*

State*

Zip Code*

Country

Phone*

Work Phone

Home Phone

Mobile Phone

Fax

Best Time to Call:

E-mail*

Web Site

Would you like to receive updates and notices from Dean & Draper?

Yes

Tell Us About Your Business

Business Type:

Corporation

S Corp

Individual

Partnership

Description of Operations:

Locations 1:

Locations 2:

Locations 3:

Locations 4:

Payroll Information: (Job Desc., # of Employees, Estimated Annual Payroll)*

Owners & Officers:
(Name, Title/% of Ownership, Duties, Include/Exclude, Est. Payroll)*

Prior History (3 years needed if applicable):
(Insurance Co./Coverage, Policy#/Dates, Premium, Num. & Total Amount of Losses)*

Please provide description of claims including dates, type of injury and amounts

Have you been non-renewed or cancelled in the past 3 years?*

Yes

Comments / Questions?

Subscribe to Groups

There currently aren't any fields under this section

For security reasons,

type in the code below:

© 2007 Dean & Draper
Home | About Dean & Draper | Contact | Site Map
Site Designed by True Light Resources
Content Management by Tendenci