15001Walden Rd., Suite 215C
Montgomery, TX 77356

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

24 Hour Turn Around on Internet Quote Requests for Home, Auto, RV, Renters, Motorcycle and Water Craft!

Our Mission:

To help our clients find the right insurance coverage's at a fair price. As an independent agency, our agency can quote your insurance through a number of different carriers to make sure you are getting a good value on your insurance products.

Kyle E. Hern, Agent
Please feel free to call me on my cell phone, 713-203-8538, or visit our contact page.

Group Health Insurance Quote

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: $200 $250 $300 $500 $1,000 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 Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family Male Female Emp. Only Emp. & Spouse Emp. & Child Emp. & Family   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.