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Business / Group Insurance Quote

Please fill out the form below in its entirity to receive a custom quote tailored to your needs for business or group health insurance. An agent will contact you by choice of phone or email if you wish to be contacted.
THE CONFIDENTIAL INFORMATION SUBMITTED BELOW WILL BE VIEWED ONLY BY INSURANCE CARRIERS AND BY TEXAS BENEFIT (HIPAA ASSOCIATES) FOR THE PURPOSE OF ASSESSING UNDERWRITING RISKS AND RATES. NO INFORMATION WILL BE AUTHORIZED FOR VIEWING BY YOUR EMPLOYER OR ANY OTHER ASSOCIATES.
*Note: We respect your privacy. Your Information is always confidential and will not be sold nor given out to any third party under any circumstances.
Is this an application for employee only of company? If yes, please skip the part below and start at Employee information.
Company Information
Business Name: Number of Employees:
Address: Type of Business:
City and State: Do you wish to be contacted by phone or email?
Zip Code: Email:
Owner/CEO Name: Phone:
Contact Person: Would you like more information by mail?
     
A. Employee Information
Employee/Officer #1 Employer Name:
Full Name: Number of family members to be insured:
Date of Birth: Smoker?
Gender: Job Description:
City: Email:
County: Phone:
State: Zip:


Employee #1 Family Information
1. Spouse
Name: Smoker?
Date of Birth: Gender:
2. Child
Date of Birth: Gender:
3. Child
Date of Birth: Gender:
4. Child
Date of Birth: Gender:
List Pre-Existing Conditions:
1:
2:
3:
4:
5:
   
Please describe any pre-existing conditions:




Other Insurance Coverage
The day your coverage begins, will any family members, including those not listed in Section B, be covered by any other health insurance or Medicare? (if yes, please complete this section)
Coverage Type:
Insurance company name:
If applying for Spouse Coverage, Is Spouse currently working?
Is Spouse Currently Eligible for Health Coverage at their employer?
(If No, give reason below ;)
Details:
We will process and return your request during normal business hours.      
Texas Benefit Offers Texas benefits to the entire State of Texas along with nationwide benefits and services.
 

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