Get-Coverage

If you have concerns or questions call 888-300-2672 and one of our agents will be happy to help you complete this application.

Select your Agent

Agent Name

Personal Information

First Name *

Last Name *

Telephone *

E-mail

Date of Birth *

Sex at Birth

Attachment

Driver’s License/ ID/ Passport *

Social Security Card *

Employment

Employer or Field of Work

Employer Telephone

Amount

Yearly Income

Dependent Information

Are you married?

Married

Unmarried

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Social Security Number

Do you have children or dependents?

Yes

Child No.	Child First Name	Child Last Name	Child Date of Birth	Child Sex
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

Insurance

Do you currently have insurance?

Yes

I give Texas Healthcare Coverage, Dennis Life and Healthcare permission to complete my application. I understand a 3 Party Verification Call will be made to me at my working telephone number to verify my application. If do not answer the call a text message and email will be sent to follow up on my Application to complete my call.

Sign Date