THIS FORM IS ONLY FOR A BUSINESS LOCATED IN THE STATE OF TEXAS. IF OUTSIDE OF TEXAS, PLEASE CONTACT JAMES ZANDER DIRECTLY.
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Company Information
Company Name
Phone Number
Fax Number
Email Address
Company Address
Nature of Business
Is this a new venture Yes No
Number of employees
Proposed Effective Date
Federal Tax ID Number
Date Business Started
Estimated Annual Payroll
Estimated Annual Sales
Does company currently have Workers' Compensation Yes No
Coverage Requested
Medical Dental Disability
Life Vision STD/LTD
Rate Information
MEDICAL CURRENT RENEWAL
Employee $ $
Employee & Spouse $ $
Employee & Child(ren) $ $
Employee & Family $ $
Dental CURRENT RENEWAL
Current Insurance Company Information
Coverage Insurance Company How Long
Medical
Dental
Vision
Life
Disability
401(K)
Plan Design
MEDICAL CURRENT Requested
Deductible
Co-Insurance
Dr. Co-Pay
Rx Co-Pay
Out-of-Pocket
Plan Maximum
Preventive %
Basic %
Major %
Annual Maximum
Orthodontia %
Orthodontia Maximum
How would you like us to contact you
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