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Employee Assistance Program Request for Quote

Employee Assistance Program - Request for Quote
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Please complete all fields to obtain a quote
Company Name:
    Contact Title:
Contact Name:
    Contact Number:
Number of Employees in the Lehigh Valley Area:
Number of Employees outside of the Lehigh Valley Area:
Current EAP (Employee Assistance Program):
Annual Rate (Per Employee Per Year):
$
Counseling Benefit Desired:


Services Desired:


Please review your information. When finished, please submit electronically via the SUBMIT button, fax to (610) 969-0439 or mail to the address below.