Texas Group Health Insurance Quote

* Required Fields
Contact Information
Business Name:
*Contact First Name:
*Contact Last Name:
*Phone Number: ( )
Alternate Number:
*Contact E-mail Address:
Address:
 
City:
State:
Zip Code:
Company Information
Number of employees:
Business description:
How long have you been in business:
What percentage will the company contribute toward the plan:
Are you currently insured: Yes | No
Benefits desired (check all that apply): HMO
PPO
 Dental
 Vision
 Disability
 Life
 
Employee Information
(If there are more than 10, comment in the remarks section below)
  1. Age: | Gender:
    Spouse coverage desired?: Yes     | No
    Child coverage: Yes     | No , If yes: Number of children:
     
  2. Age: | Gender:
    Spouse coverage desired?: Yes     | No
    Child coverage: Yes     | No , If yes: Number of children:
     
  3. Age: | Gender:
    Spouse coverage desired?: Yes     | No
    Child coverage: Yes     | No , If yes: Number of children:
     
  4. Age: | Gender:
    Spouse coverage desired?: Yes     | No
    Child coverage: Yes     | No , If yes: Number of children:
     
  5. Age: | Gender:
    Spouse coverage desired?: Yes     | No
    Child coverage: Yes     | No , If yes: Number of children:
     
  6. Age: | Gender:
    Spouse coverage desired?: Yes     | No
    Child coverage: Yes     | No , If yes: Number of children:
     
  7. Age: | Gender:
    Spouse coverage desired?: Yes     | No
    Child coverage: Yes     | No , If yes: Number of children:
     
  8. Age: | Gender:
    Spouse coverage desired?: Yes     | No
    Child coverage: Yes     | No , If yes: Number of children:
     
  9. Age: | Gender:
    Spouse coverage desired?: Yes     | No
    Child coverage: Yes     | No , If yes: Number of children:
     
  10. Age: | Gender:
    Spouse coverage desired?: Yes     | No
    Child coverage: Yes     | No , If yes: Number of children:
 
Comments
Any comments, needs or special requirements?
ENTER INFORMATION HERE FOR ALL FAMILY MEMBERS TO BE INSURED
 
  Gender Age Smoker? Height Weight
Applicant ftin lbs
Spouse ftin lbs
Child 1    
Child 2    
Child 3    
Child 4    
Child 5    
 Total number of children to be insured: 
COVERAGE / HEALTH INFORMATION
 
Will you require maternity benefits?:  Yes   No

List any health conditions such as heart problems, diabetes, etc.  If none, enter NONE:


Do you have health insurance now?  Yes   No

If YES, with which health insurance carrier? 

Any comments or special requirements?

 

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