Corporate Wellness & Safety Promotions
[businessdirectory]
Please fill out this form to the best of your knowledge.
The more information you provide the better we will be able to assist you.
Thank you.
Contact Information: (Required)
People Growers Contact (If you have one)
Company Name: *
Name: *
Title:
Company Address *
City *
State *
Zip *
Phone number: *
EXT:
Email Address: *
Number of employees
Local: *
National:
I am interested in (Check all that apply)
Health & Wellness FairSports & Fitness FestivalOnsite Biometric ScreeningOpen Enrollment ExpoFlu VaccinationsCovid 19 TestingVirtual Wellness Fair
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Company Information: (Recommended)
Host Company:
Health Insurance (PPO or HMO, % if applicable)
Dental Insurance (PPO or HMO, % if applicable)
Vision Insurance (PPO or HMO, % if applicable)
Alternative Coverage:
Industrial Clinic:
Tuition Reimbursement:
Other Benefits:
Are you self-Insured?
—Please choose an option—YesNoUnsure
Insurance Broker:
Broker Contact / Phone # / Email
Event Information: (If Applicable)
Do you have multiple locations? (If yes, how many)
Date(s) / Time of Event(s):
Event Location / Address:
Number of expected attendance:
How many exhibitors / vendors would you like?
Is this open enrollment?
—Please choose an option—YesNo
Are you including biometrics?
Do you need a bid for biometric screenings? If so, check all that apply:
Total cholesterolHDL/LDL cholesterolGlucoseBlood pressureBody FatOther: (List all that applies)
Other biometric screenings:
Any other information we should know: