Employee General Health Survey

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.

Please fill out the form and then hit “SUBMIT” Employer Name   Your Residence Town   State (abbv.)   Your Zipcode   Your First name and last Initial   Your Gender Please Select Male Female Who will be taking Coverage? Please Select Me Only Myself and spouse Only Myself and 1 child only Myself and 2 or more Children only My Family including both spouse and children Your Age Do you Smoke? Please Select Cigars Cigarettes No Your Height less than 5' 0" 5' 1" -5 '3" 5' 4" -5' 6" 5' 7" - 5' 9" 5' 10" - 6' 6' 1" - 6' 3" 6' 4" and over Please Select Your Weight Spouse Height Not taking coverage less than 5' 0" 5' 1" - 5' 3" 5' 4" -5' 6" 5' 7" - 5' 9" 5' 10" - 6' 6' 1" - 6' 3" 6' 4" and over Spouse Weight Are You or your depedent Pregnant? (If yes, please advise on estimated delivery date) Please Select Yes No Expected Delivery Month Not Pregnant January February March April May June July August September October November December For the following questions answered “YES”, please provide details in the area provided in box #5. 1. Within the last 5 years have you or any dependent who is applying for coverage received treatment, medication, or been treated for any of the following: Cancer, Stroke, Diabetes, Heart or Vascular Disease, Rheumatoid Arthritis, Lupus, Kidney or Liver Disorder, Drug or Alcohol use, HIV or Aids Please Select Yes No 2. Within the past two years, have you or any dependent who would be applying for coverage, received any counseling or treatment for mental, emotional, or behavior issues Please Select Yes No 3. Have you or any dependent applying for coverage, been hospitalized or had surgery or advised the need to have surgery that has not been completed in the past 12 months.  Please Select Yes No 4. Are you currently taking any medications? (if yes, list medications below) Please Select Yes No 5. If any “Yes” answers to Q1-Q4, please provide Details below. Upon Hitting “SUBMIT” , your e-mail program will transmit this information via e-mail.   If you do not have e-mail, please call for a fax version of this form.        Copyright © Castle Group Health Inc. 2006 Last update 1/31/2006

Any Problems?  Call us @ 847-559-8100