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Group Proposal Request Form

Current medical rates:-

Renewal rates:-

Workers comp coverage:-

Employer insurance Contribution For:-

Any claims in the past 12 months or forseeable future over $7000?:-

Any medical conditions (Example: Aids, Cancer, Diabetes, Heart, Kidney, Lungs)?:-

Are any of the insured’s or dependents currently on cobra of state continuation?:-

Do you want to see?:-

What coinsurance do you want to see?:-

What maximum Out of pocket after deductible would you like quoted? (In Network / Out Network):-

What deductibles would you like to see quoted: (In the Network / Out of the Network):-

What prescription copays would you like to see quoted: Generic / Brand / Non-Formulary:-

What Dr visit copay’s would you like quoted; Primary Visit Copay / Specialist Visit Copay:-

Enter your employee details:-

Gender:-

Questions? Contact Us today!

Toll Free: (877) 401-2199
Local: (512) 401-2100
Fax: (888) 395-7084
P.O. Box 2272
Round Rock, TX 78680