CONTACT INFORMATION By filling out this form, we can individualize any health plan to best suit your needs.  If you have specific questions to ask, please use the telephone number or email link below and we will answer you immediately. First Name Middle Name Last Name Company Name Address Line 1 Address Line 2 City State Zip Code Daytime Phone () - Evening Phone () - E-mail Address Do you prefer to be contacted by email or telephone? Best time of day to call? Who is this quote for? Gender Birthday (mm/dd/yy) Height Weight Smoker/Non-Smoker Spouse (if covered, add birthdate, smoke/nonsmoke, height & weight) Dependents (if covered, add gender, names & ages) Has anyone ever been diagnosed with Heart Disease, Cancer or Diabetes? Any Other Comments  Contact Us by Telephone or Email Address: InterTexas Insurance Agency, Inc. Attn: Jerry Jordan 18602 Rogers Lake San Antonio, TX 78258 Phone: 210-530-9600 or 1-877-325-9600 Fax: 210-530-9595 E-mail: jerjordan@sbcglobal.net Quote Information For a telephone quotation, please call us with the following information: Person or persons to be insured Date of birth Height & Weight Do you use tobacco Complete address, including zip code Telephone number