Castle Group Health Inc.
899 Skokie Blvd. - Northbrook, IL 60062
Local Phone: 847-559-8100 Toll Free: 877-559-8100

 
 
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From Our Blog

5/13/2010 3:04:00 AM
Small Business Health Insurance Credit Info
Companies with less than 25 employees who provide employer sponsored health insurance plans may be eligible for tax credits of up to 35% of the...
 

5/4/2010 2:41:00 PM
A Few Details on Health Reform Bill
The CBO now says that the passage of the health care reform act will add cost to everyone's health care costs. This is the opinion that we carried...
 

Health Questionnaire

Your Employer is considering a change of health insurance benefits.  To more accurately estimate the costs with each carrier your employer is asking some employees to fill out the following health insurance questionnaire.

The form you are about to complete is CONFIDENTIAL.  Information on this form will not be shared with your employer. It will be shared, anonymously, with insurance carriers for the sole purpose of obtaining price and coverage information.  The information, once received by our agency, is only seen by the licensed agent of Castle Group Health Inc. who requested this form.

You can reach us Toll-Free, M-F, 9am-5pm CT. @877-559-8100 With any questions.



* Required
Employer Name*  
 
Employee Name*  
 
Gender*  
 
Date of Birth*    /   / 
 
Height*    Ft.   In. 
 
Weight*     Lbs.
 
Spouse Taking Coverage?*  
 
# of Children taking Status?*  
The following set of questions appears once per child listed above.
 

Have you or any member of your family enrolling for coverage been diagnosed, received treatment, or are currently receiving treatment for any of the following conditions within the PAST 5 YEARS?* Please answer the following question for any member of your family that will be applying for coverage.

Cancer or tumor?

Diabetes?

Alcohol / Illicit drug use or abuse?

Liver Disease / Cirrohsis / Hepatitis?

Lung or respiratory conditions?

Intestinal issues / Chron's / IBS / Stomach?

Immune System?

Heart Conditions / High Blood pressur / High Cholesterol / Stroke?

Bones / Joints / Muscles / Arthritis?

Kidney / Urinary Tract / Bladder (stones, infection)?

Neurological Conditions?

Are you or your spouse or dependent currently pregnant?

Are you currently taking any prescription medications?

Any Testing or Surgery recommended, but not completed?

In the past 24 months: Had Totals Claims in excess of $5,000?

In the past 24 months: Had an MRI, NMR or stress test?

In the past 24 months: Had any surgery, inpatient or outpatient?

In the past 24 months: Been confined over night in the hospital?

In the past 24 months: Psychological Conditions or counseling?

In the past 12 months: Had an emergency room visit?

In the past 12 months: Received physical therapy or chiropractic care?

 
 
 
 
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