Monday, February 06, 2012
 
 
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Testimonials
"TACT has worked hard to keep our rates low. Their wellness screenings are wonderful. Their health training programs are a big plus. The biggest reason we like TACT is that when you have a problem, they get to work on it and resolve it immediately. When you call TACT, you get in touch with a real person the first time.
- Karen Pitcock
  Pitcock Supply, Inc.
  Lubbock, Texas
  
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Please fill out the form below and click "Submit". If you have more than 20 employees, please contact us directly.

Please fill out the form below and click "Submit". If you have more than 20 employees, please contact us directly.

Contact Information * Your Name:

* Your Email Address:

* Your Phone Number:

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Group Information Group Name:

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SIC Code:

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Current Carrier Current Carrier: Effective Date:
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Current Rates:

Renewal Rates (if available):

Current Benefits:

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Children
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Risk Information Company Name:


Number of...

Employees or dependents in this group who are pregnant.

Employees or dependents in this group who are disabled or not actively at work.

Employees or dependents in this group who are anticipating treatment in excess of $5,000 in the next twelve months.

Employees or dependents in this group who incurred $5,000 or more in claims during the past twenty four(24) months.

Employees or dependents in this group who have knowledge of or, during the past twenty four(24) months, received treatment for disease, disorder or ailment of: Blood, Immune System, Cancer, Diabetes, Heart, Kidney, Skeletal System, Respiratory System, Psychological, Alcohol or Drug Abuse.

Provide details to the previous questions in the area below. For past claims, provide diagnosis, prognosis, course of treatment (if applicable) and the approximate claim amount for all individuals.


Contact Information * Your Name:

* Your Email Address:

* Your Phone Number:

Your Fax Number:
 
Group Information Group Name:

Group Town/Zip Code:

SIC Code:

Proposed Effective Date:
Pick a date
Current Carrier Current Carrier: Effective Date:
Pick a date
Current Rates:

Renewal Rates (if available):

Current Benefits:

If less than two years with
above, list previous carrier: 		How long were you with this carrier:
Employee Census
NameSexDOBCoverageSpouse
DOB		# of
Children
Pick a date Pick a date
Pick a date Pick a date
Pick a date Pick a date
Pick a date Pick a date
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Add More Employees
Risk Information Company Name:


Number of...

Employees or dependents in this group who are pregnant.

Employees or dependents in this group who are disabled or not actively at work.

Employees or dependents in this group who are anticipating treatment in excess of $5,000 in the next twelve months.

Employees or dependents in this group who incurred $5,000 or more in claims during the past twenty four(24) months.

Employees or dependents in this group who have knowledge of or, during the past twenty four(24) months, received treatment for disease, disorder or ailment of: Blood, Immune System, Cancer, Diabetes, Heart, Kidney, Skeletal System, Respiratory System, Psychological, Alcohol or Drug Abuse.

Provide details to the previous questions in the area below. For past claims, provide diagnosis, prognosis, course of treatment (if applicable) and the approximate claim amount for all individuals.


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