Creative and Affordable Solutions with A rated companies

When you need an honest answer- give me a call.
J. Kevin Tucker
512-417-8103

Fast Response Feedback Form

Don't Worry!...Keep it simple...If this seems difficult, let's talk about it...Please give me a call or email me, & I will give you a call.  All information is kept confidential.

This form is simply to help us start with the basics. Please list in the comments section below your current coverage (deductible) and the insurance company. 

For businesses-
I will need to know what type of business it is...if you know the SIC code, or I will help you find it.
I will need a "census"- please list employees by age and home zip code. I will also need to know if the employee will want to also cover spouse &/or children.

Health Insurance

Life Insurance

Level term Insurance

Individual

Whole Life Insurance

Small Business

Universal Life

Possibly Both

More information please

Health Insurance-

Supplemental Insurance

PPO

Dental

HSA

Vision

Both options- More information

Accident

Comments:
(any additional information that may be helpful- health issues/concerns)

Name

Address:

City:

State

Zip

Phone:

E-mail:

Smoking? Y/N

#1

Age

Sex

For Individual
Health Insurance-
Covered persons

#2

Age

Smoking? Y/N

Sex

Number of children to be covered

Life Insurance Amount?

Life Insurance Term length?      10/20/30 years

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Creative and Affordable Solutions with A rated companies

To contact us:

Phone:512-417-8103
Fax: 512-832-9107
Email: ktucker@texas.net
P.O. Box 340994
Austin, TX 78734