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Our Carriers

Our Carriers Call Us: 281-391-2002

Group Health

We browse through a wide variety of coverages and find the right one for you.

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Ancillary Benefits

We browse through a wide variety of coverages and find the right one for you.

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Compliance

We browse through a wide variety of coverages and find the right one for you.

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Payroll / HR

We browse through a wide variety of coverages and find the right one for you.

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PEO

We browse through a wide variety of coverages and find the right one for you.

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Individual (personal)

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Group Information Form

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information

First Name *

Last Name *

E-Mail Address *

A) Employer Information

Group Name *

Broker Name *

Quote Effective Date *

Industry Code *

Avg # of Employees in 2020 (ATNE) *

Medicare Payer Status *

Employer FEIN *

Website *

Primary Location Street *

City *

State *

ZIP / Postal Code *

County *

B) Current Medical Coverage

Current Carrier *

Current Rate Billing Method *

Current Plan Year Effective Date *

C) Employee Statistics

Full-Time Active *

In New Hire Waiting Period *

On COBRA or Continuation *

D) Quote Request

Medical

Quote? *

Current Carrier *

Employees *

Dependents *

Notes

Dental

Quote? *

Current Carrier *

Employees *

Dependents *

Notes

Vision

Quote? *

Current Carrier *

Employees *

Dependents *

Notes

Base Life & AD&D

Quote? *

Current Carrier *

Employees *

Dependents *

Notes

Short-Term Disability

Quote? *

Current Carrier *

Employees *

Dependents *

Notes

Long-Term Disability

Quote?

Current Carrier

Employees

Dependents *

Notes

Optional Life & AD&D

Quote? *

Current Carrier *

Employees *

Dependents *

Notes

Large Groups - Sections E-F are required for large groups (51+ ATNE). Optional for small groups.

E) Carrier History - For Last 5 Years. Medical carrier history required. Ancillary carrier history helpful.

Carriers *

Effective Dates *

Termed Dates *

Coverage Types & Notes *

F) Group Medical Plan Questions

1. Are any classes of full time employees excluded from coverage? If so, please explain. *

2. Are retirees eligible for coverage? If so, how many are under 65? *

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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5702 Fourth Street | Katy, Texas 77493
P: 281-391-2002 | Fx: 281-674-8111

123 North Water Street | La Grange, Texas 78945
P: 281-391-2002 | Fx: 281-674-8111