Your Name:
Your Title/Position:
Your E-mail Address:
Company Name:
City:
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Zip Code:
County (not country)
Phone Number:
(area code first)
Best time to contact
Select
AM
PM
Evenings
(e.g. - machine shop, lawyers..)
Number of Employees
(full time only - 30+ hours)
Current Insurance Situation
Does your currently offer group health insurance ?
Select......
Yes
No
If you do not currently offer coverage, you do not need to answer the next 4 questions. You can use the CTRL key to make multiple selections.
Name of Current Insurance Carrier:
Types of insurance currently offered:
PPO
HMO
Indemnity
Hospital/Surgical Only
Reasons for Dissatisfaction withexisting plan:
Bad Plan Design
Price Increases
Customer Service
Expenses Not Covered
PPO/ HMO Network
Other
Month of Renewal of Existing. Coverage:
Not Sure
Jan.
Feb.
March
April
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
Plan Preferences (use the CTRL for multiple selections)
Types of coverage you would like quotes on:
PPO
HMO
Indemnity
Hospital Only
Additional Insurance Options Wanted:
Dental
Disability
Vision
Fertility
Additional Comments
Please provide any additional specific information about your group that will help us recommend a medical plan to meet your needs and/or budget.Include any brief information about preexisting conditions that you are concerned about obtaining coverage for.
Submit your Request for Quotation
If you prefer, please call us: toll free: 877-559-8100 - Castle Group Health Inc.
Thank You!
Within the next 1 business day we will Contact you for additional information or e-mail price and summary information to the address provided. You are welcome to provide additional information about your needs by completing the brief survey below.
(EE=EMPLOYEE, ES=EMPLOYEE+SPOUSE, EC-EMPL+CHIILD(REN), FAM=FAMILY)
Census Form: (Optional)
Gender
Age
Coverage
Gender
Age
Coverage
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
Male
Female
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
EE
ES
EC
Fam
None
