Online Information Form
Complete the form to to begin the application process.
Please provide the requested information. Important: The address provided must be the actual street address of the business where the participating workers are employed, not a Post Office box number.
Legal Name of Small, Private Business:
Contact's E-mail Address
Contact's Phone Number
Street Address Line 2
State / Province
9-digit Zip Code
Business' Total Number of Individual Employees:
Medical Insurance Provided?
Workers' Compensation or other benefits provided?
TWC Unemployment Tax Account Number
4-Digit NAICS Code that identifies your Industry:
New employees—those employed less than 12 months prior to the application submission date. Existing employees--those employed longer than 12 months of the application submission date.
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm