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

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

Our Texas Insurance Policies & Coverages

Please upgrade to the latest version of Flash Player.

Click here if you already have Flash Player installed.

Group Health Insurance Quote

Think You Can't Afford Quality Health Insurance?

Save 10 - 60% on all dental care!

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
MajorMedicalDeductible:
OptionalPregnancyCoverage: 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.