Online group health insurance quote request form for use by companies in Texas, provided by Houston broker with a broad portfolio of carriers.

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Individual Health Insurance
Dental Insurance

Group Health Insurance Quote

GROUP PROFILE
Group
City 
Zip:
Type of Business
Industry SIC Code
Email Address*
Current Agent
Proposed
Effective Date
Current Carrier
Contact Name*
Telephone #*
Fax Number
Describe your current agent
PRODUCT SELECTION
Medical Insurance Carriers to quote
 First Choice   Second Choice    Third Choice     

Describe Your Health Insurance Needs
Health plan type:  Deductible:  Co-Payment:  Co-Insurance: 

Dental Benefits to Quote
Deductible: Annual Maximum:    Ortho Coverage:    

Long Term Disability (LTD)
Elimination Period: Duration of Payments: Monthly Max: 

Group Term Life Insurance
Death Benefit:   
   

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How did you find us?     Other:
 

Healthcare Consultants | 4615 Southwest Freeway, Suite 850 | Houston, Texas 77027
713-626-2838 | Toll Free 888-626-6858 | Fax 713-626-1817 | Toll Free Fax 888-626-1817 | info@hciamerica.com

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