Private and Charter Schools Application

In order to see how we can best serve you, please fill out the form below. That will give us enough information so we can ask more specific questions about your particular situation. If you have something you would like to communicate to us please use the comment box at the bottom. If you have questions, or don’t know some of these answers, don’t worry. Send what you can and we’ll take it from there, or just pick up the phone and calls us at 800-435-3719, Extension 24.

General Information Name of School:    School Address:    City:      State:   Zip: Contact Name:      Phone #:  Email Address:     School Information # of Locations:      Year School Was Organized: Current Enrollment:      # of Teachers:  # Other Staff:      (cafeteria, janitorial, etc.)     Is Your School Accredited?   Yes No     Do You Carry Workers' Compensation?   Yes No     If "Yes" to Workers' Comp, what is Your Modifier?    Type of School:    -- Please Select -- Public Private Charter Vocational College Other  Grade Levels Served:     # of Buses/Vehicles:     School Web Address:     Additional Comments Please list any additional information, comments, or questions below:  Submit Your Application Please click on the "Submit Request" button to send your quote request. One of our representatives will respond to your submission as soon as possible.

 
If you have any questions about this application, please contact:

Brian W. Bingham, CIC
Certified School Workers' Compensation Specialist
Licensed Risk Manager

Corporate Location
2321 S. Belt Line Road, Suite 116
Grand Prairie, Texas 75051
800-435-3719
bingham@alliance-services.com

West Texas Branch
6914 82nd Street, Suite E
Lubbock, Texas 79124