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Group Health Insurance Quote
 
Group Health Insurance Quote  (Texas residents only.)
GENERAL INFORMATION
NAME OF BUSINESS
CONTACT NAME
ADDRESS
CITY
     STATE   ZIP 
COUNTY
BUSINESS PHONE  
FAX PHONE  
BEST TIME
TO CALL		  
E-MAIL ADDRESS
LOCATION ADDRESS
Type "same" if same as above.  List additional locations in the
"additional information" box at the end of the form.
CITY
     STATE   ZIP 
# OF FULL-TIME EMPLOYEES      YEARS IN BUSINESS 
PLEASE DESCRIBE YOUR BUSINESS, PRODUCT AND/OR  SERVICE
CARRIER INFORMATION
PLEASE PROVIDE INFORMATION ON YOUR CURRENT INSURANCE CARRIER
CURRENT INSURANCE CARRIER CURRENT RATES HOW LONG WITH CURRENT CARRIER
NUMBER OF CARRIERS IN
PAST 4 YEARS		 EFFECTIVE DATE HOW MANY YEARS WITH
CURENT INSURANCE CARRIER?
  (MM/DD/YY)
 
MEDICAL HISTORY
NUMBER OF EXISTING PREGNANCIES DUE DATES (If none, please type none in field)
ARE THESE INDIVIDUALS COVERED
UNDER PRESENT CARRIER		 ARE YOU AWARE OF ANY MEDICAL CONDITIONS, HOSPITALIZATIONS
OR PENDING SURGERIES IN THE GROUP?
YES    NO YES   NO   (If answered yes, please explain with details below)
LIST ANY MEDICAL CONDIITONS, HOSTPIALIZATIONS OR PENDING SURGERIES
IN THE FIELD BELOW.  (If none, please type none)
ARE ANY EMPLOYEES OR DEPENDANTS CURRENTLY ON AN EXTENSION OF COBRA?
YES    NO   (If answered yes, please explain with details below)
LIST ANY EMPLOYEES OR DEPENDANTS CURRENTLY ON AN EXTENSION OF COBRA.
PLEASE PROVIDE DETAILS  (If none,  type none)
EMPLOYEE CENSUS
AGE SEX DEPENDENT STATUS WORK LOCATION ZIP CODE
1 M  F
2 M  F
3 M  F
4 M  F
5 M  F
6 M  F
7 M  F
8 M  F
9 M  F
10 M  F
11 M  F
12 M  F
13 M  F
14 M  F
15 M  F
COVERAGE SECTION
LIFE & AD&D CLASSIC DENTAL MATERINITY
YES   NO YES   NO YES   NO
DEDUCTIBLE COINSURANCE
ADDITIONAL INFORMATION
PLEASE LIST ANY ADDITIONAL INFORMATIONI RELEVANT TO FORMULATING A QUOTE.
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