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First Name*
Last Name*
Email Address*
(Company Email)
Verify Email*
Telephone Number*   Ext:
Job Title*
   
Company Name*
Company Web Site*
(For Verification) 
Address* (For Verification)
Address 2
City*
State*
Zip Code*
Number of Employees*
Number of Locations *(If applicable)
 
Your Goals for a Wellness Program: (Check all that apply)*
Reduce Insurance Costs
Attract / Retain Employees
Reduce Absenteeism
Increase Productivity
Premium Differential (Those who participate versus those who don't)
Premium Differential (Based on health status)
Have a proactive (versus reactive) benefit plan design  
 
Interests: (Check all that apply)*
Onsite Health Screenings
Employee Training / Education Programs
Health Risk Assessment
Health Coaching / Health Management
Behavior Modification (smoking cessation, stress management, weight loss, etc.)
Employee Assistance Programs
Disease Management Programs
Incentive Programs
Fitness Center Management
Gym Discounts
Health Fairs / Wellness Fairs
Full-time / Part-time Onsite Health Promotion Expert
Health Challenges
Internet tools and other online wellness programs
Flu Shots
Points based tracking of participation 
   
When do you plan on implementing a Wellness Program?*
1-3 Months
3-6 Months
6-12 months
No firm date set
 
What is your benefit renewal date? *  

What is your company’s estimated annual budget Per Employee Per Month (PEPM) for wellness programs?.*
No employer investment
$0.01 - $0.99 PEPM
$1.00 - $1.99 PEPM
$2.00 - $2.99 PEPM
$3.00 - $3.99 PEPM
$4.00 - $4.99 PEPM
$5.00 - $5.99 PEPM
$6.00 - $7.99 PEPM
$8.00 - $10.00 PEPM
$10.00 + PEPM
 
Are you responsible for deciding how and when to pursue a Wellness Program?*
Yes, solely
Yes, as part of a group
No, who is?  
 
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By submitting information to www.WellnessProposals.com you confirm that you are an authorized representative for the above listed group and acknowledge that this free proposal service is designed to assist you in your search for wellness programming, services and / or products.*