Tennessee Insurance Plans For Employees, Family & Individuals
Serving our customers for over 30 years!
 
 

We offer employee health insurance in Tennessee, underwritten by the top insurance writers in the state.

We also offer long and short-term disability policies, dental insurance, life insurance in all its forms, long term care, accident benefits and other products and services.

 

To insure the most accurate and timely quote, please answer all fields.

                         
                                                                                                                                 
   
   
     
 

 

Employer Health Insurance Quote
  
 

For TN Based Companies Only
 
   
   
     
 

 

Census Information Form--Request for Insurance Proposal
  
   
 
   
   
     
 

Type of Business:

  
   
 
     
   
   
     
 

Business Name:

  
   
 
     
   
   
     
 

Contact Person:

  
   
 
     
   
   
     
 

Business Address:

  
   
 
     
   
   
     
 

Business Zip Code:

  
   
 
     
   
   
     
 

Phone Number:

  
   
 
     
   
   
     
 

Fax Number:

  
   
 
     
   
   
     
 

Email:

  
   
 
     
   
 
     
 

 

Employee Name
(optional)		  
     
 

 

Date of Birth
(required)		  
     
 

 

Sex
(required)		  
     
 

 

Coverage Code
(required)		  
 
   
       

Male

Female

    
             
     
       

Male

Female

    
             
     
       

Male

Female

    
             
     
       

Male

Female

    
             
     
       

Male

Female

    
             
     
       

Male

Female

    
             
     
       

Male

Female

    
             
     
       

Male

Female

    
             
     
       

Male

Female

    
             
     
       

Male

Female

    
             
     
       

Male

Female

  
           
   
       

Male

Female

    
             
     
 
 
   
 
  
   
 
 
 
   
 

**  If your company has more than 12 employees complete this form and submit it as many times as necessary.
   
 
   
   
Consumer Health Association
PO Box 3692
Brentwood, Tennessee 37024
Toll Free 1-800-613-9193
Local 1-615-360-1125
Fax 1-615-329-1942