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Group Request for Quote
Group - Request for Quote
(Information submitted via internet will be encrypted per Privacy Policy)
Please complete all fields to obtain a quote

  Group Information:
Items in bold are required.
Group Name:
    SIC Code or Nature of Business:
Contact Person:
   Email Address:
Address 1:
    Address 2:
City:
    State:
 County:
Zip:
(Ex. xxxxx or xxxxx-xxxx)
Phone:
(Ex. xxx-xxx-xxxx)
      
Current Carrier:
     
Requested Effective Date:
(Ex. mm/dd/yyyy)
 /  /
How did you hear about Valley Preferred?
(Example: billboard, newspaper, Chamber of Commerce, etc.)
Are you currently working with a Health Insurance Broker or Agent?  

  Employee Information:
Due to medical underwriting, the following question must be answered, and based on response may generate additional underwriting questions.
To the best of your knowledge, are any employees or dependents not in good health, currently disabled, currently pregnant, or recovering from a recent major illness?
Are any retirees covered?
Total Number of Full-Time Employees:
Is anyone currently on COBRA?
 Total Number of Part-Time Employees:
Number of years in business:
 Total Number of Insurance Waivers:
(Eligible employees who are declining coverage)
Coverage requested:




 
*Employee salary required (Valley Preferred account executive will contact you for salary information)

  Employee census Information:
Please provide an employee census of your group by completing the form below or emailing an electronic census (using Access, Excel or Word format only) to Valley Preferred. Electronic census submissions should also include the group name, contact person, address and phone #).
The following information is necessary to provide a quote:
employee gender, employee date of birth or age, type of coverage requested (employee, employee/spouse, employee children or family), number of children, zip code.
EMPLOYEE M/F Date Of Birth
(mm/dd/yyyy)		 Coverage Number of
Children		 Zip Code
Employee #1  /  / 
Employee #2  /  / 
Employee #3  /  / 
Employee #4  /  / 
Employee #5  /  / 
Employee #6  /  / 
Employee #7  /  / 
Employee #8  /  / 
Employee #9  /  / 
Employee #10  /  / 

Please review your information. When finished, please submit electronically via the SUBMIT button, fax to (610) 969-0439
or mail to Valley Preferred, 1605 N. Cedar Crest Blvd., Suite 411, Allentown, PA 18104.

©2012 Valley Preferred
610-969-0480
1-800-955-6620
1605 N. Cedar Crest Blvd, Suite 411
Allentown, PA 18104-2351

©2012 Lehigh Valley Health Network
610-402-CARE
Toll Free: 1-888-LVH-CARE
Cedar Crest & I-78, P.O. Box 689
Allentown, PA 18105-1556

VALLEY PREFERRED is part of Lehigh Valley Health Network, which includes three full-service hospitals in Allentown and Bethlehem, Pa., community health centers in eight counties, primary care and specialty physician offices throughout the region, pharmacies, imaging services, home health and hospice, community clinics, lab services and preferred provider services.

Lehigh Valley Health Network: Health Care Services | Lehigh Valley Physician Group | Lehigh Valley Home Care | Lehigh Valley Hospice | Health Spectrum Pharmacy Services | Lehigh Valley Magnetic Imaging Center | Health Network Labs | Valley Preferred


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