New Client - Allied - Marquee Health

New Client Form

We are delighted to have you on board as our valued new client. To ensure we provide you with the best possible service and cater to your unique needs, we kindly request you to complete our New Client Form.

New Client Form

Allied Client Form

Company Name(Required)

Number of Covered Employees(Required)

Eligibility (Medical Only or All Employees)

Allied Care Solutions Wellness Plan Design

If other, enter program type

Do you have Allied Behavioral Health?

Yes

Program Effective Date

Allied Group ID

Key Contact at Allied

Key Contact at Allied Phone Number

Key Contact at Allied Email Address

Key Contact at Client

Key Contact at Client Phone Number

Key Contact at Client Email Address

Client Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Key Contact at Broker (if applicable)

Additional Information (if applicable)

Comments

This field is for validation purposes and should be left unchanged.