Chamber ChoiceAgents and Brokers
 

 

Request a Proposal

You may complete this form for a formal proposal by mail or fax. Our staff will work diligently to forward your proposal within 3 business days. For questions or assistance, call 972-542-0163.

Contact name: REQUIRED
Telephone: REQUIRED
E-mail Address: REQUIRED
Group Name: REQUIRED
Street Address: REQUIRED
City: State:Zip:REQUIRED
Nature of Business
SIC Code		 REQUIRED
Do you currently have an agent?
Yes No
If yes, who?

Information about your current benefit plan or desired benefits:

In Network Out of Network
Deductible
Coinsurance Level
Maximum Out-of-Pocket
Office Visit Co-Pay N/A

Life Insurance:

Current Medical Insurer:  

Current Monthly Medical Premium:

Please provide a brief statement indicating the reason
that you are looking for a new insurance carrier.

Please provide a census of employees

  Age or D.O.B Sex: Coverage Status: 
1 M F Emp  Emp+Spouse Emp+Child Family
2 M F Emp  Emp+Spouse Emp+Child Family
3 M F Emp  Emp+Spouse Emp+Child Family
4 M F Emp  Emp+Spouse Emp+Child Family
5 M F Emp  Emp+Spouse Emp+Child Family
6 M F Emp  Emp+Spouse Emp+Child Family
7 M F Emp  Emp+Spouse Emp+Child Family
8 M F Emp  Emp+Spouse Emp+Child Family
9 M F Emp  Emp+Spouse Emp+Child Family
10 M F Emp  Emp+Spouse Emp+Child Family
11 M F Emp  Emp+Spouse Emp+Child Family
12 M F Emp  Emp+Spouse Emp+Child Family
13 M F Emp  Emp+Spouse Emp+Child Family
14 M F Emp  Emp+Spouse Emp+Child Family
15 M F Emp  Emp+Spouse Emp+Child Family
16 M F Emp  Emp+Spouse Emp+Child Family
17 M F Emp  Emp+Spouse Emp+Child Family
18 M F Emp  Emp+Spouse Emp+Child Family
19 M F Emp  Emp+Spouse Emp+Child Family
20 M F Emp  Emp+Spouse Emp+Child Family
21 M F Emp  Emp+Spouse Emp+Child Family
22 M F Emp  Emp+Spouse Emp+Child Family
23 M F Emp  Emp+Spouse Emp+Child Family
24 M F Emp  Emp+Spouse Emp+Child Family
25 M F Emp  Emp+Spouse Emp+Child Family
26 M F Emp  Emp+Spouse Emp+Child Family
27 M F Emp  Emp+Spouse Emp+Child Family
28 M F Emp  Emp+Spouse Emp+Child Family
29 M F Emp  Emp+Spouse Emp+Child Family
30 M F Emp  Emp+Spouse Emp+Child Family
31 M F Emp  Emp+Spouse Emp+Child Family
32 M F Emp  Emp+Spouse Emp+Child Family
33 M F Emp  Emp+Spouse Emp+Child Family
34 M F Emp  Emp+Spouse Emp+Child Family
35 M F Emp  Emp+Spouse Emp+Child Family
36 M F Emp  Emp+Spouse Emp+Child Family
37 M F Emp  Emp+Spouse Emp+Child Family
38 M F Emp  Emp+Spouse Emp+Child Family
39 M F Emp  Emp+Spouse Emp+Child Family
40 M F Emp  Emp+Spouse Emp+Child Family



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