Group Health | First Insurance Agency of the Hill Country

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Personal Information

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Please Note: We only write insurance for these states.

Address

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Street Address Address Line 2 City State ZIP Code

Name*

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First Last

Telephone Number*

What is your telepone number?

Email Address*

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Fax

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Company's Name

What is the name of your company?

Position

What is your position?

Time to Call

What is the best time to call?

:

Carrier

Does your company currently have an insurance carrier?

Yes
No

Name of Current Carrier

What is your company’s current insurance carrier?

Anniversery Date

What is the anniversery date of your current plan

What do you like or dislike about your current plan

Total number of Employees

What is the total number of employees in your company

Please enter a number from 0 to 50.

Number of Employees to be Insured

How many employees are you looking to insure?

Please enter a number from 0 to 50.

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

Employee Only
Employee and Family

My current rate for Single coverage is:

My current rate for Husband & Wife coverage is:

My current rate for Single Parent & Child coverage is:

My current rate for Full Family coverage is:

Are there any insurance carriers you would like quoted?

If yes, please list the company names

Company Name

What type of plan do you want compared?

HMO Plan
Dual Option Plan (PPO/POS)

Co-payments

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

Prescription Plan

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

Yes
No

Deductible

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

Co-insurances

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

Additional remarks or requests

Census

State

City

Zip

Employee No. 1 information

Employee No. 1 Name

First Last

Zip

Employee Gender

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Female

Employee Date of Birth

Coverage Type

Employee No. 2 information

Is there an Employee No. 2

Employee No. 2?

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Zip

Employee Gender

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Employee No. 3 information

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Employee No. 3?

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First Last

Zip

Employee Gender

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Female

Employee Date of Birth

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Employee No. 4 information

Is there an Employee No. 4

Employee No. 4?

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Zip

Employee Gender

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Female

Employee Date of Birth

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Employee No. 5 information

Is there an Employee No. 5

Employee No. 5?

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Employee Gender

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Employee No. 6 information

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Employee Gender

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Female

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Employee No. 7 information

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Employee Gender

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Employee No. 8 information

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Employee Gender

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Employee No. 9 information

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Employee Gender

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Female

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Employee No. 10 information

Is there an Employee No. 10

Employee No. 10?

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Employee Gender

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Female

Employee Date of Birth

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Employee No. 11 information

Is there an Employee No. 11

Employee No. 11?

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Employee Gender

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Female

Employee Date of Birth

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Employee No. 12 information

Is there an Employee No. 12

Employee No. 12?

Employee No. 12 Name

First Last

Zip

Employee Gender

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Female

Employee Date of Birth

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Employee No. 13 information

Is there an Employee No. 13

Employee No. 13?

Employee No. 13 Name

First Last

Zip

Employee Gender

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Employee Date of Birth

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Employee No. 14 information

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Employee No. 14?

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Employee Gender

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Female

Employee Date of Birth

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Employee No. 15 information

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Employee No. 15?

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First Last

Zip

Employee Gender

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Female

Employee Date of Birth

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Employee No. 16 information

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Employee No. 16?

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First Last

Zip

Employee Gender

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Female

Employee Date of Birth

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Employee No. 17 information

Is there an Employee No. 17

Employee No. 17?

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Zip

Employee Gender

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Female

Employee Date of Birth

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Employee No. 18 information

Is there an Employee No. 18

Employee No. 18?

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Zip

Employee Gender

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Female

Employee Date of Birth

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Employee No. 19 information

Is there an Employee No. 19

Employee No. 19?

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Zip

Employee Gender

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Female

Employee Date of Birth

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Employee No. 20 information

Is there an Employee No. 20

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Employee Gender

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Employee No. 21 information

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Zip

Employee Gender

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Female

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Employee No. 22 information

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Employee No. 22?

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Employee Gender

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Female

Employee Date of Birth

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Employee No. 23 information

Is there an Employee No. 23

Employee No. 23?

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Employee Gender

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Female

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Employee No. 24 information

Is there an Employee No. 24

Employee No. 24?

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Employee Gender

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Employee No. 25 information

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Employee No. 25?

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Employee Gender

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Employee No. 26 information

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Employee Gender

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Employee No. 27 information

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Employee Gender

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Employee No. 28 information

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Employee No. 28?

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Employee Gender

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Female

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Employee No. 29 information

Is there an Employee No. 29

Employee No. 29?

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Employee Gender

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Employee No. 30 information

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Employee No. 30?

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Employee Gender

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Female

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Employee No. 31 information

Is there an Employee No. 31

Employee No. 31?

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Employee Gender

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Female

Employee Date of Birth

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Employee No. 32 information

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Employee No. 32?

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Employee Gender

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Employee No. 33 information

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Employee No. 33?

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Employee Gender

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Employee No. 34 information

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Employee Gender

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Employee No. 35 information

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Employee Gender

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Employee No. 36 information

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Employee Gender

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Employee No. 37 information

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Employee Gender

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Employee No. 38 information

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Employee Gender

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Employee No. 39 information

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Employee No. 40 information

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Employee No. 41 information

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Employee Gender

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Employee No. 42 information

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Employee Gender

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Employee No. 43 information

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Employee Gender

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Female

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Employee No. 44 information

Is there an Employee No. 44

Employee No. 44?

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Employee Gender

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Female

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Employee No. 45 information

Is there an Employee No. 45

Employee No. 45?

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Employee Gender

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Female

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Employee No. 46 information

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Employee No. 46?

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Employee Gender

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Female

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Employee No. 47 information

Is there an Employee No. 47

Employee No. 47?

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Employee Gender

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Female

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Employee No. 48 information

Is there an Employee No. 48

Employee No. 48?

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Zip

Employee Gender

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Female

Employee Date of Birth

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Employee No. 49 information

Is there an Employee No. 49

Employee No. 49?

Employee No. 49 Name

First Last

Zip

Employee Gender

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Female

Employee Date of Birth

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Employee No. 50 information

Is there an Employee No. 50

Employee No. 50?

Employee No. 50 Name

First Last

Zip

Employee Gender

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Female

Employee Date of Birth

Coverage Type

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