Texas Alliance of Nonsubscribers

Texas Alliance of Nonsubscribers Online Application For more information you may contact: 512-542-3389


Type of membership sought:	Nonsubscribing member Associate
Company Name:	*
Mailing Address:	*
City:	*
State:	*
Zip Code:	*
Name of Contact:	*
Title of Contact:
Email of Contact:	*
Phone:	* (i.e. ###-###-####)
Fax:

For Nonsubscribing Member Applicants:
# of Texas employees on January, 30 :
# of Texas employees on August, 30 :

For Associate Member Applicants:
Type of Company:	Third Party Administrator Business Associate Insurance Carrier Other

	Please enter the text from the image above:
* Verify:



Your company will be billed for its dues based on the following guidelines: Membership to the organization is open to nonsubscribing businesses in Texas who maintain an occupational injury benefits plan. Regular member dues for 2007 will be $1.00 per Texas employee based on the company’s average headcount using January 30th and August 30th of the previous year to determine the average. Minimum dues for employers with greater than 250 Texas employees are $1,500. Dues for small employers with fewer than 250 employees are $500. Dues are capped at $15,000 regardless of the number of employees. The term of membership is 12 months.

Printable Applications Click here to download a printable version of the Membership Application (in PDF format). Click here to download a printable version of the Associate Membership Application (in PDF format).