Wednesday, February 8, 2012

Apply for a Texas Health Plan Quote

Texas Health Plans works with a nationwide network of agents who can provide you with accurate health insurance quotes. Get started now!

Step 1: Please Complete a General Medical Profile

Gender

Date of Birth
(MM / DD / YYYY)

Height

Weight
(lbs)

Smoker?

Full-time College Student?

Applicant*

/ /

Spouse

/ /

Children

Child 1

/ /

Child 2

/ /

Child 3

/ /

Child 4

/ /

Child 5

/ /

When would you like coverage to begin?*

/ /

Are you currently insured?*

yes no

Who is your current insurance company?

Do you currently take any medications?*

yes no

Please specify: *

Do any of the people applying for health insurance have any pre-existing health conditions?*

yes no

Please check all pre-existing health conditions that apply to any of the people listed above:*
	Aneurysm	Cancer	Clinical Depression
	Diabetes	Drug/Alcohol Abuse	Emphysema
	Heart Disease	HIV/AIDS	Hypertension
	Kidney Disease	Liver Disease	MS
	Paralysis	Stroke	Other Major Illness

Step 2: Provide Your Contact Information
First Name*		Last Name*
Address*		City*
State*		Zip Code*
Day Phone*	- -	Evening Phone*	- -
Best Time to Contact*		Email Address*

I have read and agree to the Privacy Policy and the Site Terms of Use.