Broker Application

Request A Proposal

Information Required for a Proposal

Call 1-800-245-1150 or email marketing@behavioralhealthsystems.com to request a proposal. The following information, along with 1-2 years of claims data, would be beneficial in preparing a quote for your client:

Organization's Name:

Street Address:

City:

State:

Zip:

Website Address:

Number of Employees:

Type of Business:

Contact Name*:

Title:

Email Address:

Phone Number:

Fax Number:

Service model requested
(if applicable):

Other information that
would be useful to us:

Proposal Needed by
this date:

Number of copies
requested:

 


For information purposes only. We will make contact with your client directly only if requested by you or your client.