15001 Walden Road, Suite 215C
Montgomery, TX 77356

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

Group Health Insurance Quote Online

 

 

(Texas residents only, please.)

Please provide the following information:
General Information
Legal Name of Business:
Contact Name:
Address:
City: State: Zip:
Business Phone: Fax:
Best Time To Call: AM PM
Contact Email Address:
Type of Business
Type of Business:
Standard Industry Code (if known):
# of Full Time Employees: # of Part Time Employees:
Give a complete description of any type of hazardous/dangerous duties performed by your employees:

Current Group Health Insurance Information

Carrier(Company)Name(notagency):
Please give a brief description of your current Group Health plan:

Benefits Desired

Major Medical Deductible: Optional Pregnancy Coverage: yesno
Dental Coverage: yesno Supplemental Accident Coverage: yesno
Disability Insurance: yesno PCS Card:
(Prescription Discount Option)
yesno
Group Life Insurance:

Amount:

yesno

$

PPO Option: yesno
HMO Option: yesno

Employee Information

Please list all employees you wish to cover:
Employee Name Date of Birth
Age
Sex
Dependent Status
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
 

If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or email an additional listing.

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.