Group Family and Individual Health Insurance Texas, Long Term Care, Medicare, Dental, Travel

Individual & Family

Group Health

Seniors

Life

Long Term Care

Dental

Short Term Medical
Insurance

Companies

GROUP HEALTH INSURANCE QUOTE REQUEST

Please complete the following information and Census Form if you would like to obtain a group health insurance quote. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
If you have more than 50 employees, just submit the form twice. You only need to enter the company name and your email address on the second form, along with the employee information.

Census

Company Name

State

City

Zip

Employee Data

Employee No.

Birth Date (mm/dd/yy)

Zip Code

Gender

Select Coverage

Employee 1

Employee 2

Employee 3

Employee 4

Employee 5

Employee 6

Employee 7

Employee 8

Employee 9

Employee 10

Employee 11

Employee 12

Employee 13

Employee 14

Employee 15

Employee 16

Employee 17

Employee 18

Employee 19

Employee 20

Employee 21

Employee 22

Employee 23

Employee 24

Employee 25

Employee 26

Employee 27

Employee 28

Employee 29

Employee 30

Employee 31

Employee 32

Employee 33

Employee 34

Employee 35

Employee 36

Employee 37

Employee 38

Employee 39

Employee 40

Employee 41

Employee 42

Employee 43

Employee 44

Employee 45

Employee 46

Employee 47

Employee 48

Employee 49

Employee 50

Personal Information

What is your name?

Last

First

Middle

What is the name of your company?

Company's Name

What is your address?

Street

City

State

Zip

What is your position?

Position

What is your e-mail address?

e-mail

What is your telephone number?

Telephone

What is your fax number?

Fax

What is the best time to call?

Time to Call

Does your company currently have an insurance carrier?

Carrier

Yes No

If you have a carrier, what is it?

Name of Current
Carrier

If you have a carrier, what is the anniversary date of your current plan?

Anniversary
Date

What is the total number of employees in your company?

Total Number of
Employees

How many employees are you looking to insure?

Number of
Employees
to be Insured

Are premiums paid by your company for employee only or family, too?

Employee Only

Employee and Family

My current rate for coverage is:

Single
Husband & Wife
Single Parent &
Child
Full Family

Are there insurance carriers you would like quoted?

If yes, please list the company names

What type of plan do you want compared?

HMO Plan
Dual Option Plan
(PPO/POS)

HMO Plan
Dual Option Plan

If you want an HMO or Dual Option Plan compared, choose from the following co-payments:

Co-payments

If you want an HMO or Dual Option Plan compared, do you want a prescription plan?

Prescription Plan

Yes No

If you want Dual Option Plan compared, please choose from the following deductible:

Deductible

If you want Dual Option Plan compared, please choose from the following co-insurances:

Co-insurances

What do you like or dislike about your current plan?

Likes or Dislikes

Additional remarks or requests

Remarks or
Requests

For a quote click on the submit button below

    Health Insure Plus
    4287 Belt Line Rd #354
    Addison, TX 75001
    (972) 733-0870
    (877) 733-0870