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Self Funded Request for Quote
Self Funded - Request for Quote
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Please complete all fields to obtain a quote

  Group Information:
Group Name:
    Contact Person:
Address 1:
    Address 2:
City:
 
State:
 Zip:
 County:
Phone:
    Fax:(optional)
 Email Address:
Current Carrier:
    Plan Design Name:
Monthly Premium:
$
Requested Effective or Renewal Date: (mm/dd/yyyy)
 /  /

  additional Information:
Current Third Party Administrator:
Contact Name:
 Contact Number:
Current Network:
 Plan Design:

EAP Services: (Employee Assistance Programs)
Current Vendor:

Utilization Management Services:
Current Vendor:

Disease Management Services:
Current Vendor:

Requested Effective Date: (mm/dd/yyyy)
 /  /
Number of Employees:
 

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

©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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