Corporate Wellness & Safety Promotions
People Growers of America Contact (if you have one)
Date Submitted
Broker Contact
Broker Phone Number
[honeypot fax-992 id:fax]
Broker Email
Host Corporation (Required)
Your Name (Required)
Your Position
Your Email Addresss (Required)
Your Phone Number (Required)
Your Fax Number
Address of Event Location
Date & Time of the Event
IndoorOutdoor *If outdoors, under canopiesYesNo
Location of Venue
Company Contact
Title
Phone
Email
No. of Employees Total
Employees on Site
Expected Attendance
Health Ins. (PPO or HMO, % if applicable)
Dental Ins. (PPO or HMO, % if applicable)
Vision Ins. (PPO or HMO, % if applicable)
Chiropractic Coverage: (PPO or HMO, % if applicable)
Industrial Clinic
Tuition Reimbursement (amount per employee)
Is this open enrollment?Are you including biometrics?Do you want people growers to organize biometrics?Do you want people growers to organize shots?
Which exhibitors do you already have in the event
Parking and Security Instructions
Special clothing or shoe requirements
Do you need bids for biometric screenings? If so, list below: Total cholesterolHDL/LDL cholesterolGlucoseBlood pressureBody fatOther:
Other
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: