<%@LANGUAGE="VBSCRIPT" CODEPAGE="1252"%> Coast Professional Services, Inc. - Oregon Health Insurance Source

Group Health Quote Request

The quote you have requested requires that you complete the following survey as completely and accurately as possible. Once submitted the information will be e-mailed to our office(s) and we will expedite your request. This information will be kept confidential and will be used for quote purposes only. We look forward to serving you.

Fields marked with a Red asterisk * are required.

Fields marked with a Blue asterisk * , at least 1 of the fields must be filled in.

Contact Information
* Company Name:
Company Address:
Company City:	State: Zip:
Type of Business:
SIC Code:
* Your Name:
* Your Home Zipcode:
Your Phone:	* Work:
	* Home:
	Fax:
*Your Email Address:

Type of Coverage

Doctor Visit Copay: Yes   No

Prescription Copay Card: Yes   No

Plan Type:

Hospital Deductible:

Coinsurance:

Group Life: Yes   No       Amount:

Group Dental: Yes   No

List any specific companies you would like quotes from:

List any major medical conditions associated with this group:
(cancer, diabetes, heart)

Employee Census

Please list all employees you wish to cover:

Employee Name Date of Birth (DOB)
Gender
Spouse DOB
(if applicable)
# of Children

Male
Female

Male
Female

Male
Female

Male
Female

Male
Female

Male
Female

Male
Female

Male
Female

Male
Female

Male
Female

Male
Female

Male
Female

Male
Female

Male
Female

Male
Female

If you have more than 15 employees, simply submit this form additional times. You will only need to enter the company name on the other submissions.

Additional Considerations/Requests

Please give any additional comments you feel appropriate for this quotation.

Please click on the "Submit Request" button to send us your quote request.

Oregon Insurance License: 610301