Texas insurance from Jerry Molina Insurance Agency
FAST & FREE Online Texas Auto, Homeowners & Life Insurance Quotes!
Select Your Free Quote Below!
  
Personal Auto, Homeowners Insurance from Jerry Molina Insurance Agency
Personal Auto Insurance

Homeowners Insurance

Flood Insurance

Motorcycle Insurance

Mexican Auto Insurance

Health Insurance

INSTANT ONLINE Unicare Health Insurance Quote


Commercial and Business Insurance from Jerry Molina Insurance Agency
McAllen Investment Properties

Commercial Auto Insurance

Workers Comp Insurance

Group Health Insurance


Other Insurance Services from Jerry Molina Insurance Agency
Mortgage Protection

Term & Whole Life Quotes

Service My Account

More About Our Agency

Office Map/Directions

Our Privacy Notice

 
On-Line Workers
Compensation Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal / Company Data:

Your Name:
Your Company's Name:
Street Address:
City:
State: (Must be Texas)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again (for accuracy):
Phone:
Fax (optional):
 

Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE)
 
List Claims & Amounts Paid
(If none, type NONE)
 
Years In Business:
 
Business type:
(proprietorship, corporation, etc.)
 

 
Underwriting Information:
 
Describe IN DETAIL,
Your Business Operations:
 
Payroll Class #1:
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here: 		$
 
Payroll Class #2: (if none, leave blank)
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here: 		$
 
Payroll Class #3: (if none, leave blank)
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here: 		$
 
 
Send my quotation via: E-Mail Fax
Regular Mail

 
Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a
Workers Compensation Quote NOW!

Click Button Below When Done

Please Click Only Once . . . May take up to 30 seconds!

Jerry Molina Insurance Agency . 3313 N Ware Road, Suite 1 . McAllen TX 78501
Toll Free Phone: 1-888-668-8889 . Phone: 1-956-661-8338 . Fax: 1-956-661-0110
Our Normal Office Hours are: 9:00 to 5:00, Weekdays | View Our Privacy Notice
E-Mail us at: quotes@jerrymolina.com | Website Design © 2006, Insurance Web Sales