Texas Mutual Workers Comp Enrollment Form

Annual Dues for new members = $100

New Enrollment

*Membership Type

	Fee		Name
	$100.00		Texas Mutual Workers Comp: Annual Premium $1 - $25,000
	$100.00		Texas Mutual Workers Comp: Annual Premium $25,000 - $50,000
	$100.00		Texas Mutual Workers Comp: Annual Premium $50,000 - $75,000
	$100.00		Texas Mutual Workers Comp: Annual Premium $75,000 - $100,000
	$100.00		Texas Mutual Workers Comp: Annual Premium $100,000- $200,000
	$100.00		Texas Mutual Workers Comp: Annual Premium $200,000 - $300,000
	$100.00		Texas Mutual Workers Comp: Annual Premium $300,000 -$400,000
	$100.00		Texas Mutual Workers Comp: Annual Premium $400,000 -$500,000
	$100.00		Texas Mutual Workers Comp: Annual Premium Over $500,000