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Let's "Be Better" together! Tell us a little about your needs and we'll be in touch shortly.
Internet communication is not checked on evenings, weekends, federal holidays, or states of emergency requiring business closure. For immediate assistance, please call 800-968-8143.
Please select one:

Agent/RepresentativeEmployer/Organization
AGENT'S/REPRESENTATIVE'S INFORMATION
Organization*
Name*
Address

Street Address

Street Address Line 2

CityState

ZIP Code
Phone Number*
Example: (123) 123-4567
Email*
PROSPECT'S CONTACT INFORMATION
Prospect's Organization*
Prospect's Name*
Prospect's Title
Prospect's Phone Number
Example: (123) 123-4567
Prospect's Address

Street Address

Street Address Line 2

CityState

ZIP Code
Prospect's Website Address
Health Care Provider
Average Number of Employees*
Does the organization have an EAP?

YesNo
Organization's State Locations*
EMPLOYER'S INFORMATION
Your Organization*
Contact's Name*
Contact's Title
Contact's Phone Number*
Example: (123) 123-4567
Contact's Address

Street Address

Street Address Line 2

CityState

ZIP Code
Contact's Email*
Website Address
Health Care Provider
Average Number of Employees*
If you are working with an agent, please list agent's name.
Organization's State Locations*
Does your organization have an EAP?

YesNo
PROPOSAL DETAILS
Full Service EAP — Select your counseling sessions and life management services (LMS). All plans receive unlimited workplace consultations and unlimited access to our Well-being and Training Center. Choose all that apply.

3 counseling / 5 LMS8 counseling / 5 LMS5 counseling / 5 LMSOther
Spark Products — Add services to fill gaps in your EAP or benefits offerings. Choose all that apply.

HealthySpark — 3 counseling sessions / unlimited LMS / unlimited access to the Well-being and Training CenterBizSpark — 3 sessions per workplace referral / unlimited HR and leadership consultationsLifeSpark — Unlimited LMS / unlimited access to the Well-being and Training Center
One-time service agreement — We can help when you don't have an EAP. Choose all that apply.

Counseling SessionsLife Management ServicesWorkplace ServicesConsultation Services
Special Services — Please call us at 800-968-8143 to discuss your crisis or training needs.

Disruptive Event Management — on-site presence to assist employees and leadersTraining — On-site and virtual for employees, leaders and the workplace
Desired Start Date

MonthDayYear
Date
Date Proposal Needed*

MonthDayYear
Date
How did you find out about us?*
Please list any concerns with your current vendor or reason for seeking an EAP.
Type in a question.
Please be aware that electronic communication via the internet cannot be guaranteed to be completely free from potential breaches of privacy and confidentiality. If security is a concern for you, please call us at 800-968-8143.
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