Free Wellness Program Proposals And Health Promotion Proposals

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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.*

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