Commercial Benefit Services, Inc.

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If you are interested in an individual plan for you and/or your family, please fill out the form below. You will be given the most competitive quotes.

Please provide us with all requested information and be sure it is true and correct to determine the best possible rates.

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:
Applicant Gender:
Applicant Date of Birth:
Applicant Use any tobacco products:
Spouse Date of Birth:
Spouse use any tobacco products:
Spouse Occupation:
Children Coverage Desired:
Number of Children:
Products Desired: Health  Dental  Life  Disability
Medical Deductible Desired:
Present Insurance Carrier Name:
Office Copay:
RX Copay:
Deductible:
Coinsurance:
Rates:
Notes:

Please contact me as soon as possible regarding this matter.

 

 

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Commercial Benefit Services, Inc.

10301 Northwest Freeway, Suite 304

Houston, Texas  77092

(713) 956-5522 phone

(713) 956-0588 fax
 

Copyright©2000, Commercial Benefit Services, Inc. All rights reserved.

 
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