15001 Walden Road, Suite 215C
Montgomery, TX 77356

1-866-TEXAS-45
(1-866-839-2745)

Affordable Texas Life Insurance and Texas Health Insurance Quotes

 

Affordable Texas Life Insurance and Texas Health Insurance Quotes

 

(Texas residents only, please.)

INSTRUCTIONS :
Please complete this form so that we can refer you to a life and health specialists. The specialist will work with you to provide you with a quote on your health insurance. After you submit this form, the specialist will compare pricing for various companies and determine what carrier has the best plan for your needs.
Insured Information
Which type of quote do you need?
(Check all that apply)
LIFE HEALTH
1. Last Name , First Name :
2. Address :
3. City :
4. State:
5. Zip Code :
6. Home Phone :
7. Work Phone : ext :
8. Fax Number :
9. Email Address :
10. Sex:
11. Date of Birth :
12. Age:
13. Height: ' "
14. Weight: lbs.
15. Occupation :
16. Employer's Phone :
17. Employer's Fax :
18. Are you a smoker:
19. Do you use other tobacco products:
20. Are you a non-smoker:
Spouse's Information
1. Last Name, First Name:
2. Sex :
3. Date of Birth :
4. Age:
5. Height :
6. Weight : lbs.
7. Occupation :
8. Employer's Phone :
9. Employer's Fax:
10. Smoker :
11. Uses other tobacco products :
12. Non-smoker:
Child's Information Child #1 Child #2
1. Last, First :
2. Sex :
3. Date of Birth :
4. Age :
5. Height :
6. Weight : lbs. lbs.
7. Smoker :
8. Uses other tobacco products :
9. Non-Smoker :
Child #3 Child #4
1. Last, First :
2. Sex :
3. Date of Birth:
4. Age :
5. Height :
6. Weight : lbs. lbs.
7. Smoker :
8. Uses other tobacco products :
9. Non-Smoker :
Coverage Needed
(Check all that apply)
1. Life 2. Health 3. Short-Term Health
4. Dental 5. Disability 6. Long-Term Care
Medical History
If you have or have had any of the conditions listed below, please select that condition and to the right give a brief history and list treatments.
Heart Circulation Problems/HBP/Stroke
Lung Disorder/Asthma
Cancer (incl. skin)
Diabetes: diet control/oral meds/insulin
AIDS/ARC
Mental/Nervous/ADD
Alcohol/Drug Disorder
Medical expense of $5000+ in the last yr.
Pregnancy/Disability
Hazardous Hobbies (i.e. flying, skydiving)
Auto / Boat / Motorcycle / Dirt-bike racing
Mountain-climbing / scuba diving / Other
List any current medications
Health Quote Submittal
Please verify that all the information you have entered is correct. Then click on the Submit button to send us your request for a quote: