Applications & Forms

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Interactive eQuote Request Section

We offer a selection of online forms to help facilitate a speedy quote back to you.

INTERACTIVE QUOTE REQUEST FORMS: (CLICK LINK TO VIEW)

#	Name	Description	Link
1.	AUTO INSURANCE QUOTE	Auto Insurance Quote - Interactive	Auto
2.	HOME INSURANCE QUOTE	Home Insurance Quote - Interactive	Home
3.	BUSINESS INSURANCE QUOTE	Business Insurance Quote - Interactive	Business

Brochures

#	Name	Description	Link
1.	AGENCY SALES BROCHURE	Tri-Fold Brochure	Brochure

Applications & Forms

We offer a selection of Standardized ( ACORD) Insurance Applications & Forms to help facilitate speedy quotes and/or underwriting reviews. These applications do not bind any requested coverage as written notice of approval & acceptance of coverage may only be issued to by the issuing insurance companies underwriting staff . We are authorized representatives for several leading insurance carriers and/or Managing General Agencies. ACORD applications are generally accepted by insurance carrier underwriting departments as these forms have been approved by most State Insurance Regulatory Departments. Customized Business Insurance/ Homeowners / Non-Standard Auto Programs that have been developed for a Specific Risk Groups or Business Classifications by a carrier and/or Managing General Agencies we represent. Applications for other business classification or insurance product lines not listed herein may be requested by calling us at 1-800-361-8734 or emailing: edhemphill@hemphillinsuranceagency.

Interactive Fillable PDF Forms

Adobe PDF Downable Form

PERSONAL AUTO RELATED FORMS: (CLICK LINK TO DOWNLOAD ~ VIEW ~ PRINT )

#	Name	Description	Download Link	Fillable Link
1.	ACORD 90TX	Texas Personal Auto Application
2.	ACORD 11	Auto Accident Information Form
3.	ACORD2	Automobile Loss Notice
4.	E.I.A. CHANGE	Coverage Change Request
5.	DPS DL-64	Change Address/Updated License
6.	FORM 130U	Motor Vehicle Title Application
7.	VTR-14G	Address Change Vehicle Registration
8.	VTR-60	Replacement License Plate/Sticker
9.	VTR-214	Application For Disabled Person
10.	ACORD 12	Exchange Of Information Form
11.	ACORD 13	Witness Card
12.	TEXAS DPS	New Resident Auto Information
13.	TXDOT	Tips To Prevent Auto Theft

HOMEOWNERS / DWELLING RELATED FORMS: (CLICK LINK TO DOWNLOAD ~ VIEW ~ PRINT )

#	Name	Description	Download Link	Fillable Link
1.	ACORD 80	Homeowners Application
2.	ACORD 84	Dwelling Fire Application
3.	ACORD1	Property Loss Notice
4.	ACORD 42	Residential Property Replacement Cost
5.	ACORD 18	Jewelry Appraisal And Claim Evaluation
6.	ACORD 67TX	Homeowners Personal Property Supplement
7.	BAD RO23A	Residential Homestead Exemption Application
8.	E.I.A. CHANGE	E.I.A. Coverages Change Form
9.	TEXAS FAIR PLAN	Description Of Coverages
10.	TEXAS FAIR PLAN	Frequently Asked Questions
11.	TX 50-135	Application For Disabled Veteran Exemption
12.	ACORD 64TX	Application For Windstorm And Hail Insurance
13.	ACORD 69TX	TX Special Mobile Home Windstorm/Hail App

COMMERCIAL / BUSINESS RELATED FORMS: (CLICK LINK TO DOWNLOAD ~ VIEW ~ PRINT )

#	Name	Description	Download Link	Fillable Link
1.	ACORD 160	Businessowners Policy - Application
2.	ACORD 185	Restaurant/Tavern Supplement
3.	ACORD 125	Commercial Insurance Application
4.	ACORD 126	Commercial General Liability
5.	ACORD 127	Business Auto Application
6.	ACORD 129	Vehicle Schedule - Business Auto
7.	ACORD 137TX	Texas Commercial Auto Application
8.	ACORD 140	Commercial Property Section
9.	ACORD 163	Commercial Auto Driver Information
10.	ACORD 146	Commercial Equipment Floater
11.	ACORD 138TX	Texas Garage and Dealers
12.	ACORD 175	Commercial Policy Change Request
13.	ACORD 28	Evidence of Commercial Insurance
14.	ACORD 3	Liability Notice of Claim
15.	ACORD 130	Workers Compensation Application
16.	ACORD 4	Workers Compensation - 1st Report of Injury or Illness
17.	FSS-4	Employer Federal Tax Id - Application

OTHER FORMS: (CLICK LINK TO DOWNLOAD ~ VIEW ~ PRINT )

#	Name	Description	Download Link	Fillable Link
1.	ACORD 82	Watercraft Application
2.	ACORD 83	Personal Umbrella Application
3.	ACORD 35	Cancellation Request/Policy Release
4.	ACORD 36	Agent Of Record Change

Interactive Fillable MSWORD.DOC Forms

Interactive Fillable PDF Forms

Adobe PDF Downable Form

WORKERS COMPENSATION APPLICATIONS & RELATED FORMS: (CLICK LINK TO DOWNLOAD ~ VIEW ~ PRINT )

#	Name	Description	Fillable MSWORD DOC	Download PDF Link	Fillable PDF Link
1.	ACORD 130	Workers Compensation Application
2.	ACORD 4	Workers Compensation - First Report of Injury or Illness
3.	EEProvForm.doc	Texas Mutual - Employee Provider Form EP-1a
4.	5606Questions.doc	Texas Mutual - Executive Supervisor Questionnaire (5606)
5.	IndContractorQuestions.doc	Texas Mutual - Independent Contractor Questionnaire
6.	Peo_newclient.doc	Texas Mutual - Professional Employer Organization New Client
7.	Peo_questionnaire04.doc	Texas Mutual - Professional Employer Organization Questionnaire
8.	StartSupAp05.doc	Texas Mutual - Start Program Supplemental Application
9.	AircraftSuppApp.doc	Texas Mutual - Supplemental Application Aircraft Operations
10.	LHWapp.doc	Texas Mutual - Supplemental Application Longshore and Harbor Act
11.	Jonesapp.doc	Texas Mutual - Supplemental Application Jones Act
12.	OCSapp.docotherstates.doc	Texas Mutual - Supplemental Application Outer Continental Shelf
13.	Otherstates.doc	Texas Mutual - Supplemental Application Other States Endorsement
14.	Supedw.doc	Texas Mutual - Supplemental Employee Data Worksheet
15.	ConcEE-Tempsvc.doc	Texas Mutual - Supplemental Employee Worksheet - Temp Services
16.	Truck_Industry_Quest.docT	Texas Mutual - Trucking Industry Questionnaire
17.	Dwc81.pdf	TDIl - DWC-81, Agreement Between General Contractor and Subcontractor to Provide Workers’ Compensation Insurance
18.	Dwc82.pdf	TDI - DWC-82, Agreement Between Motor Carrier and Owner Operator to Provide Workers’ Compensation Insurance Coverage / Agreement to Require Owner Operator to Act as Employer
19.	Dwc83.pdf	TDI - DWC-83, Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers / Agreement to Establish Employer-Employee Relationship for Certain Building and Construction Workers
20.	Dwc84.pdf	TDI - DWC-84, Exception to Application of Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers
21.	Dwc85.pdf	TDI - DWC-85, Agreement Between General Contractor and Subcontractor to Establish Independent Relationship
22.	WC-RFI.doc	TDI - Workers' Compensation- Request for Information

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