Phone:832.612.0472
Email:info@lifefoundationhomecare.com
Hours of Operation:Monday-Friday 9:00am to 5:00pm

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Health Insurance Questionnaire

Insurance Feasibility Questionnaire

We are exploring the feasibility of offering group health insurance for our eligible employees. In order to perform the feasibility, we need to know who is interested in taking health insurance if offered through work. Your answers below will help us assess the need. Thank you for your help

Name(Required)

First

Last

If offered, would you be interested in getting health insurance under Life Foundation Home Care group health insurance plan?(Required)

Yes

No

Could you help us by telling us why you are not interested in health insurance? Select all that apply

I already have insurance

I can’t afford it

Don’t wish to answer

Do you have dependents that you would include on your plan?

Yes

No

Please provide Dependent Information. Please include all of them, click on + to add more dependents. Only spouse or eligible children can be covered

Relationship (Spouse/Child)

First Name

Last Name

Date of Birth

Sex (M/F)

Terms of Use(Required)

I understand that this is not an offer or acceptance of insurance. If insurance is offered and if you are eligible, you will have an opportunity to confirm enrollment at that time

Signature(Required)

About Us

Life Foundation Home Care is an award winning Texas based Home Care agency that provides quality and affordable in-home care in Greater Houston, Dallas-Fort Worth and Beaumont-Port Arthur area including Houston, Katy, Sugar Land, Stafford, Missouri City, Bellaire, Pearland, Richmond, Rosenberg ... Read More

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12808 W Airport Blvd, Ste 260L Sugar Land, TX 77478
832.612.0472
info@lifefoundationhomecare.com

Dallas Office
5301 Alpha Road, Suite 80 - 57, Dallas, TX 75240
214.764.9878

San Antonio Office
7550 W IH-10 Suite 800 San Antonio, TX 78229
210.571.0120

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