Texas Construction Trust Self-Insured GroupWorkers' Compensation Program
Dear Insurance Agent:
Please use this form to request a TCA membership application for you client who is not already a member of TCA or is not a member of one of our Member Associations. If your client is a member of one of these associations, it is likely that no additional dues will be required to participate in our workers' compensation program. Also, if not already a member, your client may join one of these associations and no additional dues will be required to participate in our worker's Compensation program as the Member Association pays dues to TCA for your client.
Member Associations of TCA
American Subcontractors Association of TexasAssociated Plumbing-Heating-Cooling Contractors of TexasCentral Texas Subcontractors AssociationDFW Drywall & Acoustical Contractors AssociationFire Equipment Distributors of TexasMechanical Contractors Association of TexasNational Electrical Contractors AssociationSheet Metal & Air Conditioning Contractors - North Texas ChapterSouthwest Terrazzo Contractors AssociationTexas Council Painting & Decorating Contractors of AmericaTexas Fire Sprinkler Contractors AssociationTexas Glass AssociationTexas Iron Worker Employers AssociationTexas Masonry CouncilTexas Structural Steel Institute
Your Agency Information
Your name:
Your email:
Your agency:
Your Telephone:
Producer's name:
Your Fax:
Agency Address
City State Zip
Your Client's Information
Company Name w/dba
Company Address
Trade and Primary WC Class Code
Standard Premium (from quote sheet ~ before any modifiers of discounts)
Effective Date of Coverage
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