Hello.

Thank you for your interest in Cattle Raisers Insurance. We look forward to hearing from you.

If you need to speak with someone directly please give us a call at: 1-800-252-2849 or click on the button below the representative on the right with whom you’d like to speak.

If you need a quote on GROUP MEDICAL insurance, download this form to email in, fill it out and fax it to 817-977-6775, or fill out the form below. We’ll have answers for you right away!

Group coverage can be quoted at any point within the calendar year, effective dates are either the 1st or the 15th of the month.
Approval is not guaranteed.

Contact Name *

First

Last

Requested Start Date *

Business Name *

Full Business Address *

Email *

Phone Number *

Nature of Business *

Current Coverage (Choose One) *

Individual
Group*
TSCRA Association

*If on current group coverage please remit your most recent renewal documents, or your current plan design(s), rates and renewal date.

How did you hear about Cattle Raisers Insurance?

Employee 1 Information: *

Please list all eligible employees. If dependents will be covered, please list their information as well.

Employee 1: Date of Birth *

Employee 1: Gender *

Male
Female

Employee 1: Home Zip Code *

Employee 1: Coverage Election *

EO - Employee Only
ES - Employee + Spouse
EC - Employee + Children
EF - Employee + Family
Waive - Has other coverage
Declines coverage

Employee 1: Dependent Information

Employee 1: Additional Dependents

Be sure to list gender and date of birth for each additional dependent listed here.

Employee 2 Information: *

Please list all eligible employees. If dependents will be covered, please list their information as well.

Employee 2: Date of Birth *

Employee 2: Gender *

Male
Female

Employee 2: Home Zip Code *

Employee 2: Coverage Election *

EO - Employee Only
ES - Employee + Spouse
EC - Employee + Children
EF - Employee + Family
Waive - Has other coverage
Declines coverage

Employee 2: Dependent Information

Employee 2: Additional Dependents

Be sure to list gender and date of birth for each additional dependent listed here.

Employee 3 Information:

If you do not have additional employees to list please enter NONE for this line

Employee 3: Date of Birth

Employee 3: Gender

Male
Female

Employee 3: Home Zip Code

Employee 3: Coverage Election

EO - Employee Only
ES - Employee + Spouse
EC - Employee + Children
EF - Employee + Family
Waive - Has other coverage
Declines coverage

Employee 3: Dependent Information

Employee 3: Additional Dependents

Be sure to list gender and date of birth for each additional dependent listed here.

Employee 4 Information:

If you do not have additional employees to list please enter NONE for this line

Employee 4: Date of Birth

Employee 4: Gender

Male
Female

Employee 4: Home Zip Code

Employee 4: Coverage Election

EO - Employee Only
ES - Employee + Spouse
EC - Employee + Children
EF - Employee + Family
Waive - Has other coverage
Declines coverage

Employee 4: Dependent Information

Employee 4: Additional Dependents

Be sure to list gender and date of birth for each additional dependent listed here.

Employee 5 Information:

If you do not have additional employees to list please enter NONE for this line

Employee 5: Date of Birth

Employee 5: Gender

Male
Female

Employee 5: Home Zip Code

Employee 5: Coverage Election

EO - Employee Only
ES - Employee + Spouse
EC - Employee + Children
EF - Employee + Family
Waive - Has other coverage
Declines coverage

Employee 5: Dependent Information

Employee 5: Additional Dependents

Be sure to list gender and date of birth for each additional dependent listed here.

Employee 6 Information:

If you do not have additional employees to list please enter NONE for this line

Employee 6: Date of Birth

Employee 6: Gender

Male
Female

Employee 6: Home Zip Code

Employee 6: Coverage Election

EO - Employee Only
ES - Employee + Spouse
EC - Employee + Children
EF - Employee + Family
Waive - Has other coverage
Declines coverage

Employee 6: Dependent Information

Employee 6: Additional Dependents

Be sure to list gender and date of birth for each additional dependent listed here.

Additional Employees:

Please list any additional employees after the above. Include date of birth, gender, zip code and coverage election for each employee listed.
*PLEASE NOTE: if you do not list all the required information, your quote will not include these employees.

Comment

Ask Us Your Questions.

Michele Woodham
Executive Director,
Insurance Services
800-252-2849 ext. 109

Email Michele

Jeanette Ortega
Group Account Manager
800-252-2849 ext. 124

Email Jeanette

Hello.

Thank you for your interest in Cattle Raisers Insurance. We look forward to hearing from you.

If you need a quote on GROUP MEDICAL insurance, download this form to email in, fill it out and fax it to 817-977-6775, or fill out the form below. We’ll have answers for you right away!

If you need to speak with someone directly please give us a call at: 1-800-252-2849 or click on the button below the representative below with whom you’d like to speak.

Group coverage can be quoted at any point within the calendar year, effective dates are either the 1st or the 15th of the month.
Approval is not guaranteed.

Contact Name *

First

Last

Requested Start Date *

Business Name *

Full Business Address *

Email *

Phone Number *

Nature of Business *

Current Coverage (Choose One) *

Individual
Group*
TSCRA Association

*If on current group coverage please remit your most recent renewal documents, or your current plan design(s), rates and renewal date.

How did you hear about Cattle Raisers Insurance?

Employee 1 Information: *

Please list all eligible employees. If dependents will be covered, please list their information as well.

Employee 1: Date of Birth *

Employee 1: Gender *

Male
Female

Employee 1: Home Zip Code *

Employee 1: Coverage Election *

EO - Employee Only
ES - Employee + Spouse
EC - Employee + Children
EF - Employee + Family
Waive - Has other coverage
Declines coverage

Employee 1: Dependent Information

Employee 1: Additional Dependents

Be sure to list gender and date of birth for each additional dependent listed here.

Employee 2 Information: *

Please list all eligible employees. If dependents will be covered, please list their information as well.

Employee 2: Date of Birth *

Employee 2: Gender *

Male
Female

Employee 2: Home Zip Code *

Employee 2: Coverage Election *

EO - Employee Only
ES - Employee + Spouse
EC - Employee + Children
EF - Employee + Family
Waive - Has other coverage
Declines coverage

Employee 2: Dependent Information

Employee 2: Additional Dependents

Be sure to list gender and date of birth for each additional dependent listed here.

Employee 3 Information:

If you do not have additional employees to list please enter NONE for this line

Employee 3: Date of Birth

Employee 3: Gender

Male
Female

Employee 3: Home Zip Code

Employee 3: Coverage Election

EO - Employee Only
ES - Employee + Spouse
EC - Employee + Children
EF - Employee + Family
Waive - Has other coverage
Declines coverage

Employee 3: Dependent Information

Employee 3: Additional Dependents

Be sure to list gender and date of birth for each additional dependent listed here.

Employee 4 Information:

If you do not have additional employees to list please enter NONE for this line

Employee 4: Date of Birth

Employee 4: Gender

Male
Female

Employee 4: Home Zip Code

Employee 4: Coverage Election

EO - Employee Only
ES - Employee + Spouse
EC - Employee + Children
EF - Employee + Family
Waive - Has other coverage
Declines coverage

Employee 4: Dependent Information

Employee 4: Additional Dependents

Be sure to list gender and date of birth for each additional dependent listed here.

Employee 5 Information:

If you do not have additional employees to list please enter NONE for this line

Employee 5: Date of Birth

Employee 5: Gender

Male
Female

Employee 5: Home Zip Code

Employee 5: Coverage Election

EO - Employee Only
ES - Employee + Spouse
EC - Employee + Children
EF - Employee + Family
Waive - Has other coverage
Declines coverage

Employee 5: Dependent Information

Employee 5: Additional Dependents

Be sure to list gender and date of birth for each additional dependent listed here.

Employee 6 Information:

If you do not have additional employees to list please enter NONE for this line

Employee 6: Date of Birth

Employee 6: Gender

Male
Female

Employee 6: Home Zip Code

Employee 6: Coverage Election

EO - Employee Only
ES - Employee + Spouse
EC - Employee + Children
EF - Employee + Family
Waive - Has other coverage
Declines coverage

Employee 6: Dependent Information

Employee 6: Additional Dependents

Be sure to list gender and date of birth for each additional dependent listed here.

Additional Employees:

Comment

Ask Us Your Questions.

HTML tutorial Michele Woodham
Executive Director, Insurance Services
800-252-2849 ext. 109

Email Michele

HTML tutorial Jeanette Ortega
Group Account Manager
800-252-2849 ext. 124

Email Jeanette