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Group Health Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!


Your Personal/Group Data:
 
Your Name:
Your Business Name:
Street Address:
City:
State: (Must be Texas)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
(If more than 5 in group, contact us at: {telephone} )

Please Check the Group Products your company wants
to make available to your employees:

Group Health   Group Dental   Group Vision
Group Life   Employee Benefits

Group Underwriting Information:

Employee #1 Name

M/F

Age

Status

 

 

 

 

Occupation

Status

Currently Insured?

Plan type

 

 

 

Employee #2 Name

M/F

Age

Status

 

 

 

 

Occupation

Salary

Currently Insured?

Plan type

 

 

 

Employee #3 Name

M/F

Age

Status

 

 

 

 

Occupation

Salary

Currently Insured?

Plan type

 

 

 

Employee #4 Name

M/F

Age

Status

 

 

 

 

Occupation

Salary

Currently Insured?

Plan type

 

 

 

Employee #5 Name

M/F

Age

Status

 

 

 

 

Occupation

Salary

Currently Insured?

Plan type

 

 

 

 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)
 
Employee Health Problems?
(Do any of your employees have special health problems or insurance needs? If no, write "none".)
 
Group Plan Needs?
(Tell us what features you want in your group plan so that we may get the coverage and benefits you are looking for!)


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Superior Insurance, Inc. | 1347 19th Street | Plano, TX 75074
Phone: 972-423-2300 | Fax: 469-361-3359 | E-Mail: quotes@superiorinsuranceinc.com
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