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- Required field.
Coverage Requested:
Medical
Vision
Dental
Rx
Type of Plan Requested:
Individual
Group Self-Funded
Group Fully-Insured
Company Name:
Contact Name & Title
*
:
Number of Employees:
Address
*
:
City
*
:
State
*
:
Zip
*
:
Phone
*
:
Email:
*
:
How did you hear about us?
Broker Advertisement
Current PHC/PPHN/Unity Member
Employer
Former PHC/PPHN/Unity Member
Mailer
Provider
Relative/Friend - Former or Current PHC/PPHN/Unity Member
Website
Word of Mouth
Current Health Plan Provider:
Type of Plan:
PPO
HMO
POS
Renewal Date
*
:
Current Broker:
Comments:
How to Request A Quote
How a Claim is Processed
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Preferred Health Care
Sterling Center 20-D • East Roseville Road • Lancaster, PA 17601
Phone: 717-560-9290 • Fax: 717-560-2312 • Email:
info@phcunity.com
