Group Health Insurance Quote Request
 
Please complete the form below or call our office at (903) 581-2400 to speak with a health insurance specialist.
Company Name (REQUIRED):
Address:
City:
County:
State: TEXAS
Zip Code (REQUIRED):
E-Mail Address (REQUIRED):
Phone Number:
Fax Number (Optional):
Current Carrier:
Expiration Date:

CONTACT & COMPANY INFORMATION

Company Contact:
SIC or NAICS Code:
Nature of Business :
Renewal or requested effective date:

# of full-time employees:
(30 plus hrs per week)

Current Plan deductible:
Current Employee Only Premium:
Renewal Employee Only premium:

Any Comments:

We will provide you with different Deductible and Co-Insurance Options.

Thank you for completing our online quote form. We will send you a quote within five business days.

Please let us know how you would like us to send you the quote: 

E-mail Fax Phone Call

Please note, this is only a quote and does not bind coverage in any way.

© Copyright 2002 Sellers - Patterson & Associates.  All Rights Reserved.