25329 Interstate 45 N, Suite 101 The Woodlands, TX 77380

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

Our Texas Insurance Policies & Coverages

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Life & Health Quote

(Texas residents only, please.)

Think You Can't Afford Quality Health Insurance?

 Save 10 - 60% on all dental care!

 
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: