Confidential Request for Proposal

Please complete this request form so we can send you a proposal without delay. You will be contacted by a CONCERN representative within two business days.

* Mandatory Fields

I am a:

Brokerage Firm:

Branch Location / Name:

Address:

City:

State:

Postal Code:

Your Name:

Title:

Email Address:

Phone:

Producer's Name:

Title:

Email Address:

Phone:

Employer Group Legal Name:

Headquarters location (City):

State:

Web Site:

Number of benefited EEs:

Requested EAP benefit plan design

EAP Plan starting date:

Number of counseling visits in plan:

Work / Life Benefits:

Yes
No

Wellness Programs:

Yes
No

Anything else?:

Current EAP plan provider: :

Why is the group looking? :

CONCERN: EAP,1503 Grant Rd, Suite 120, Mountain View, CA 94040 Tel 800 344-4222