Marilyn K. Smith Insurance
Phone: 903-759-1112
  Toll Free 800 259-0743
Fax: 903-759-8015

2814 Bill Owens Parkway, Suite 300
Longview, TX 75605
msmith1657@aol.com

Business Hours:
Monday - Friday 9:00 a.m. - 5:00 p.m.

Marilyn K. Smith Insurance
2814 Bill Owens Parkway, Suite 300 | Longview, TX 75605
Phone: (903) 759-1112 | Fax: (903) 759-8015
Toll Free 800 259-0743

E-Mail: msmith1657@aol.com

BlueCross, BlueShield
 

Group Insurance

We would appreciate it if you would take a few moments to answer the following questions. Please be assured that we do not share or sell personal information about you except when we have your permission.
Name of Group
Street Address
City
State
Zip Code
Bold = Required field
Current Insurance Carrier
If none, please indicate
Requested Effective Date
Exact Type of Industry
SIC or NAICS Code
(taken from Emploers TWC Report)
Health Plan Requested
PPO
HSA
Deductible Amount
Prescription Drug Card
Maternity
Life Amount Requested
Dental
Contact Name
Phone Number
E-Mail Address

Please attach any known medical conditions and send an e-mail to msmith1657@aol.com

Attach Census of Employees – Include the following information:
1. Name of Employee
2. Date of Birth or Age of Employee
3. Sex
4. Type of Coverage (Emp. Only; Emp./Child(ren); Emp./Spouse; Emp. Family)
5. Home Zip Code (if not the same as employers zip)

Marilyn K. Smith Insurance is the educated choice for quality coverage at excellent rates. Our reliable agents work hard to listen to your particular needs and requirements and to provide you with the perfect policy to suit your group’s lifestyles and specific circumstances. We believe that everyone has a right to be protected and so we offer premium coverages to suit any budget.

Give us a call today for a hassle-free quote.

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