Wednesday, March 10, 2010
 
 
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"We are happy with TACT because they said in the beginning they would help keep costs low…and they did. Plus the personal service is wonderful.
- Paul Wilson
  United Cotton Growers
  Levelland, 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:

Your Fax Number:
 
Group Information Group Name:

Group Town/Zip Code:

SIC Code:

Proposed Effective Date:
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Current Carrier Current Carrier: Effective Date:
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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
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DOB		# of
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
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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Pick a date Pick a date
Pick a date Pick a date
Pick a date Pick a date
Pick a date Pick a date
Pick a date Pick a date
Pick a date Pick a date
Pick a date Pick a date
Pick a date Pick a date
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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