Applicant Information

First Name:

Last Name:

Address:

City:

TEXAS

Zip Code:

Daytime Phone:

Cell Phone:


Email:  (Required)


How Best To Contact You:
Select One Cell Phone Daytime Phone Email

Currently Insured:
Select One Yes No

Date of Birth:

Gender:
Select One Female Male
Height:

Weight:


Do You Smoke:
Select One Yes No

Age of Spouse:



Currently Own Health Insurance:
Select One Yes No

Type of Health Insurance Owned:
Select One HMO PPO POS Major Medical Provided by Employer Other

How Many Children to Insure:
Select One none 1 2 3 4



Choose Coverage and Limits

Health Insurance Coverage For:
Select One Applicant Only Applicant & Spouse Applicant & Children Applicant, Spouse & Children Other


HMO Health Insurance

HMO Co-Pay Amount Desired:
Select One None $15 $20 $30


PPO Health Insurance

PPO Deductible Amount Desired:
Select One None $250 $500 $1,000


POS Health Insurance

POS Co-Pay Amount Desired:
Select One None $15 $20 $30


Major Medical Health Insurance

Major Medical Deductible Desired:
Select One None $250 $500 $1,000



Choose Additional Benefit Options

Dental Insurance

Vision Insurance

Life Insurance



Medical Information

Within the last 10 years have you
or any person to be insured been
aware of, diagnosed and /or been
treated by a member of the medical
profession for: heart disease or
disorder, stroke, cancer, diabetes,
drug or alcohol dependency, mental
disorder, emphysema, airway or
pulmonary disease, crohn's disease
or ulcerative colitis, nervous system
disorder, liver disorder, kidney
disorder, crippling or disabling
arthritis, spinal disc disease,
knee or hip disorders?

Select One Yes No


If Yes, please list serious health
problem(s) below:





During the last 10 years have you
or any person to be insured been
diagnosed by a member of the
medical profession as having
Acquired Immune Deficiency
Syndrome (AIDS) or AIDS related
complex (ARC) or tested positive
for HIV?

Select One Yes No



Have you or any person to be
insured been hospitalized within
the past 12 month, due to be so
confined or been disabled for
more than 5 days within the
past 12 months?

Select One Yes No


If Yes, please explain below:





Question or Message:




Click the "Submit Quote Request"
button below to send your Texas
Health Insurance request to
Texans Insurance & Financial Group.


***By submitting this request you
acknowledge that this is neither
an offer to insure nor a guarantee
of insurance.***








We are a Sugar Land, TX insurance
agency offering affordable Texas
health insurance policy quotes
in the following towns, cities and
counties in the Houston, Texas area:
Meadows, Town West, Four Corners,
Crabb, Booth, Thompsons, Houston,
Manvel, Pleak, Kendleton, Eagle Lake,
Sandy Point, Beasley, Rosenberg,
Richmond, Orchard, Fulshear, Juliff,
Arcola, Needville, Frydek, Rosharon,
Bonney, East Bernard, Lissie, Elm Grove,
Spanish Camp, Wharton, Guy, Bellville,
Wallis, Pasadena, Deer Park, Fresno,
Pearland, Galena Park, Jacinto City,
La Porte, Bellaire, West University Place,
Cloverleaf, Beaumont Place, Spring
Valley, South Houston, Iowa Colony,
Hilshire Village, Humble, Houmont Park,
Friendswood, League City, Alvin, Mission
Bend, Stafford, Missouri City, Texas City,
Webster, Dickinson, Baytown,
Channelview, Highlands, Seabrook,
Bacliff, La Marque, Jersey Village, Lake
Jackson, Surfside Beach, Algoa,
Santa Fe, Barker, Katy, Sealy, Dayton,
Angleton, Freeport, Bammel, Kohrville,
Bay City, Brenham, Addicks, Brookshire,
San Felipe, Hockley, Waller, Prairie View,
New Caney, Beach City, Nassau Bay,
North Houston, Hempstead, Tomball,
The Woodlands, Burr, Iago, Boling,
Peters, Cat Spring, Burleigh, Waller
County, Wharton County, Brazoria
County, Harris County, and Fort Bend
County, TX. We can also offer a Texas
health insurance quote
throughout the Lone Star state, including
in Beaumont, Austin, Waco, Fort Worth,
Dallas, and San Antonio, TX.


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