People Growers of America Contact (if you have one)

    Date Submitted

    Broker Contact

    Broker Phone Number

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    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

     

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      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

      --------------- Optional Fields Below ---------------

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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?

      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?

      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: