<% Function SendMailCDONT(Subject, ToAddress, FromAddress, Content) Err.clear Set objNewMail = CreateObject("CDONTS.NewMail") objNewMail.BodyFormat = 0 objNewMail.MailFormat = 0 objNewMail.From = FromAddress objNewMail.to = ToAddress objNewMail.Subject = Subject objNewMail.Body = Content objNewMail.Send set objNewMail=Nothing If Err.number <> 0 Then SendMailCDONT = 0 Else SendMailCDONT = 1 End If End Function Function FormatOutput(strHTML) FormatOutput = strHTML End Function Function SendMailJMail(toPart,fromPart,subjectPart,bodyPart, sAttach) Set JMail = Server.CreateObject("JMail.SMTPMail") If InStr("localhost",Request.ServerVariables("Server_Name")) > 0 Then JMail.ServerAddress = "10.1.5.194" elseIf InStr("ipi-0250",Request.ServerVariables("Server_Name")) > 0 Then JMail.ServerAddress = "10.1.5.194" else JMail.ServerAddress = "217.72.249.150" end if 'JMail.ServerAddress = "164.164.95.121:25" '' smtp.mySMTPserver.com:25 JMail.Sender = fromPart JMail.AddRecipient (toPart) JMail.Subject = subjectPart JMail.ContentType="text/html" JMail.body = bodyPart If sAttach <> Null Or Trim(sAttach) <> "" then JMail.Attachment = sAttach End if JMail.Priority = 3 JMail.Execute() SET JMail = Nothing End Function Function sendMail(sSubject, sTo, sfrom, strmail) 'response.Write "sTo=" & sTo & "
" Dim mymail, arrAttachnant, arrAttachnantPath, iKey, objCDOSYSCon set mymail = CreateObject("CDO.Message") Set objCDOSYSCon = Server.CreateObject ("CDO.Configuration") ' Outgoing SMTP server If InStr("localhost",Request.ServerVariables("Server_Name")) > 0 Then objCDOSYSCon.Fields("http://schemas.microsoft.com/cdo/configuration/smtpserver") = "10.1.5.194" elseIf InStr("ipi-0250",Request.ServerVariables("Server_Name")) > 0 Then objCDOSYSCon.Fields("http://schemas.microsoft.com/cdo/configuration/smtpserver") = "10.1.5.194" else objCDOSYSCon.Fields("http://schemas.microsoft.com/cdo/configuration/smtpserver") = "217.72.249.150" end if ' Change this to the IP address or hostname of your SMTP Server objCDOSYSCon.Fields("http://schemas.microsoft.com/cdo/configuration/smtpserverport") = 25 'Change this to the Port of your SMTP server (25 is the default) objCDOSYSCon.Fields("http://schemas.microsoft.com/cdo/configuration/sendusing") = 2 objCDOSYSCon.Fields("http://schemas.microsoft.com/cdo/configuration/connectiontimeout") = 60 objCDOSYSCon.Fields.Update ' Update the CDOSYS Configuration Set mymail.Configuration = objCDOSYSCon mymail.Subject = sSubject mymail.From = sfrom mymail.To = sTo 'mymail.Bcc = sBCc mymail.HTMLBody = strmail 'mymail.Attachment = sAttach 'If sAttach <> Null Or Trim(sAttach) <> "" then 'mymail.AddAttachment sAttach, "", "" 'Response.write "Atachment: " & sAttach &"
" 'Response.end 'mymail.AddAttachment sAttach 'End if mymail.Send set mymail = nothing End Function %> <% Dim StrMsg StrMsg = "" If UCASE(Request.ServerVariables("REQUEST_METHOD")) = UCase("POST") Then If Request.Form("chkmedicalbenefitbooklet") = 1 Then MBF = "Yes" Else MBF = "No" End If If Request.Form("chkmedicalbillingstatements") = 1 Then MBS = "Yes" Else MBS = "No" End If If Request.Form("chkmedicalrenewalrates") = 1 Then MRR = "Yes" Else MRR = "No" End If If Request.Form("chkmedicalfullyinsured") = 1 Then MFI = "Yes" Else MFI = "No" End If If Request.Form("chkmedicalselfinsured") = 1 Then MSI = "Yes" Else MSI = "No" End If If Request.Form("chk4015500Form") = 1 Then F4015500 = "Yes" Else F4015500 = "No" End If If Request.Form("chk401plandocuments") = 1 Then PD401 = "Yes" Else PD401 = "No" End If If Request.Form("chk401plansummary") = 1 Then PS401 = "Yes" Else PS401 = "No" End If StrMessage = StrMessage & "Items Required for Quoting
" StrMessage = StrMessage & "Medical:
" StrMessage = StrMessage & "Benefit Booklet - " & MBF & "
" StrMessage = StrMessage & "Billing Statements - " & MBS & "
" StrMessage = StrMessage & "Renewal Rates (when available) - " & MRR & "
" StrMessage = StrMessage & "Fully Insured - Claim Experience (2 years) When Provided By Carrier - " & MFI & "
" StrMessage = StrMessage & "Self Insured - Claim Experience (2 years) Month by Month with Enrolled Census - " & MSI & "
" StrMessage = StrMessage & "
" StrMessage = StrMessage & "401(K):
" StrMessage = StrMessage & "5500 Form - " & F4015500 & "
" StrMessage = StrMessage & "Plan Documents - " & PD401 & "
" StrMessage = StrMessage & "Plan Summary - " & PS401 & "
" StrMessage = StrMessage & "
" StrMessage = StrMessage & "List of Companies group plan with during last 5 years:
" CompanyName = Split(Request.Form("txtcompany"), ",") EDP = Split(Request.Form("txteffectivedateplan"), ",") PlanType = Split(Request.Form("txttypeofplan"), ",") For intCount = 0 To UBound(CompanyName) IF Trim(CompanyName(intCount)) <> "" Then StrMessage = StrMessage & "Company - " & CompanyName(intCount) & "
" StrMessage = StrMessage & "Effective Date of Plan - " & EDP(intCount) & "
" StrMessage = StrMessage & "Type of Plan - " & PlanType(intCount) & "
" StrMessage = StrMessage & "
" End If Next StrMessage = StrMessage & "
" StrMessage = StrMessage & "Employer Contribution:
" StrMessage = StrMessage & "Employee - " & Request.Form("txtemployercontributionemployee") & "
" StrMessage = StrMessage & "Dependent - " & Request.Form("txtemployercontributiondependent") & "
" StrMessage = StrMessage & "Explanation (If employer does not contribute) - " & Request.Form("txtemployercontibutemsg") & "
" StrMessage = StrMessage & "Total number of eligible employees on the payroll - " & Request.Form("txtemployeesonpayroll") & "
" StrMessage = StrMessage & "Total number of participating Employees enrolled in all plans - " & Request.Form("txtemployeesenrollallplans") & "
" StrMessage = StrMessage & "Retired employees currently insured - " & Request.Form("txtretiredemployeesinsured") & "
" StrMessage = StrMessage & "Former employees under COBRA - " & Request.Form("txtformaremployeescobra") & "
" StrMessage = StrMessage & "Estimate of annual turnover % in last 12 months - " & Request.Form("txtestimateturnover") & "
" StrMessage = StrMessage & "How long has this organization been in business - " & Request.Form("txthowlongbusiness") & "
" StrMessage = StrMessage & "Has there been any history of bankruptcy - " & Request.Form("selbankruptcyhistory") & "
" StrMessage = StrMessage & "
" EmpName = Split(Request.Form("txtemployeename"), ",") DOB = Split(Request.Form("txtdob"), ",") Sex = Split(Request.Form("txtsex"), ",") EnrollStatus = Split(Request.Form("txtenrollstatus"), ",") EmployeeZip = Split(Request.Form("txtemployeezip"), ",") EmployeeState = Split(Request.Form("txtemployeestate"), ",") EmployeeOccupation = Split(Request.Form("txtemployeeoccupation"), ",") Salary = Split(Request.Form("txtemployeesalary"), ",") COBRAStatus = Split(Request.Form("txtcobrastatus"), ",") For intCount = 0 To UBound(EmpName) IF Trim(EmpName(intCount)) <> "" Then StrMessage = StrMessage & "Employee Name - " & EmpName(intCount) & "
" StrMessage = StrMessage & "Date of Birth - " & DOB(intCount) & "
" StrMessage = StrMessage & "Sex - " & Sex(intCount) & "
" StrMessage = StrMessage & "Enrollment Status - " & EnrollStatus(intCount) & "
" StrMessage = StrMessage & "Employee Zip Code - " & EmployeeZip(intCount) & "
" StrMessage = StrMessage & "Enrollment State - " & EmployeeState(intCount) & "
" StrMessage = StrMessage & "Employee Occupation - " & EmployeeOccupation(intCount) & "
" StrMessage = StrMessage & "Employee Salary - " & Salary(intCount) & "
" StrMessage = StrMessage & "COBRA Status - " & COBRAStatus(intCount) & "
" StrMessage = StrMessage & "
" End IF Next 'StrTo = "dchhabra@infoprocorp.com" 'StrFrom = "dheeraj.chhabra@infoproworldwide.com" StrTo = "info@capitalbenefitsinc.com" StrFrom = "info@capitalbenefitsinc.com" StrSubject = "Employee Benefit Services Quote" SendMailCDONT StrSubject, StrTo, StrFrom, StrMessage StrMsg = "Thankyou for submitting your Pension Quote Request. We will get back to you soon." End If %> Capital Benefits
">
Capital Benefits I
Home I About Us I Industries I Services Carrier Links I State Links Forms I Contact Us
 
  Industries Served
   
  Public & Private
  Pensions Plans
  Business Benefits
  Individual Services
  Ancillary Products
 
  <%IF Trim(StrMsg) <> "" Then%> <%End IF%>
<%=StrMsg%>
Employee Benefit Services
Items Required for Quoting
Medical 401(k)
Benefit Booklet 5500 Form
Billing Statements Plan Documents
Renewal Rates (when available) Plan Summary
Fully Insured – Claim Experience (2 years) When Provided By Carrier    
Self Insured – Claim Experience (2 years) Month by Month with Enrolled Census    
 
1 - List all insurance companies you have had group plans with during the past 5 years, including your current company.
<%For intcount = 1 To 2%> <%Next%>
Company Effective Date of Plan                              Type of Plan
2 - Employer Contribution:  Employee    Dependent
3 - If employer does not contribute, please explain in detail :   
Total number of eligible employees on the payroll: 
4 - Total number of participating Employees enrolled in all plans: 
Retired employees currently insured:   Former employees under COBRA:
  (Identify these employees on census)
5 - Estimate of annual turnover % in last 12 months: How long has this organization been in business:
6 -Has there been any history of bankruptcy?: 

Census Data to include: (For diskette or Email please use Excel format)
E-Mail Census to: jca@capitalbenefits.com

                                                    
<%for intcount = 1 To 2%> <%Next%>
Employee Name Date of Birth Sex Enrollment Status * Employee Zip Code Employee State Employee Occupation** Employee Salary COBRA Status

 * Please use the following Enrollment Status Codes

  • SGL = Single Employee
  • H&W = Employee & Spouse
  • P&C = Employee & Child(ren)
  • FAM = Family
  • Waiver = No Benefits
    (Note any employees who are on COBRA /NJ Continuation)
** Required information for LTD/STD and multiple of salary Life coverage only
 
 
   
  363 Route 46 West
Suite 140
Fairfield, NJ 07004
Phone: 973-808-2626
Fax: 973-808-2627
Email: info@capitalbenefits.com
 
  Life Insurance and Annuities offered by
Metropolitan Life Insurance Company
New York, NY 10166

Mutual Funds offered by
MetLife Securities, Inc.
New York, NY 10166