Group Health
Insurance
Quote
 

We would like to provide you with a free, no-obligation group health insurance quote. Please complete ALL information so that we may provide you with a quote. This information will be kept confidential and will be used for quote purposes only.

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Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.

Disclaimer
I understand that this does not constitute an actual "live" online quote, but is rather a submission of information to Head Insurance Group so that they may put together an insurance proposal (quote) for the above titled risk. There is no obligation on my part to purchase this insurance, and I understand that this online submission does not constitute a statement or contract for insurance.

 I have read and agree with the above disclaimer.
  (Box must be checked before request can be sent)

General Information
Legal Name of Business:
Contact Name:
Address:
City:   State:   Zip:
Business Phone:   Fax:
Best Time To Call:   AM   PM
Contact Email Address:


Type of Business
Type of Business:
Standard Industry Code (if known):
# of Full Time Employees:         # of Part Time Employees:
Give a complete description of any type of hazardous/ dangerous duties performed by your employees:

 
Current Group Health Insurance Information
Carrier (Company) Name (not agency):
Please give a brief description of your current Group Health plan:


Benefits Desired
Major Medical Deductible:
    Optional Pregnancy Coverage: yes  no
Dental Coverage: yes  no Supplemental Accident Coverage: yes  no
Disability Insurance: yes  no PCS Card:
(Prescription Discount Option)
yes  no
Group Life Insurance:

 
Amount:

yes  no

$

PPO Option: yes  no
HMO Option: yes  no


Employee Information
Please list all employees you wish to cover:
Employee Name
Date of Birth
Age
Sex
Dependent Status
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
If you were not able to list all employees you wish to cover in the spaces above,
please use the Additional Comments section below
or indicate that you will fax or email an additional listing.


Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.


Before Submitting Your Information...
I understand that all of the above information MUST BE COMPLETED in order to obtain an Insurance Quote. Head Insurance Group will be unable to provide me an insurance quote if any fields above are left blank or are partially filled in. PLEASE re-check your information before submitting!

 I have read and agree with the above disclaimer.
  (Box must be checked before request can be sent)

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   


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Cedar Park
201 S. Lakeline Blvd. Ste. # 304
Cedar Park, TX 78613
Phone:
Toll Free:
Fax:
Email:
  512-336-2929
  866-377-2929
  512-336-2930
  info@headinsurancegroup.com

Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.

 
 
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