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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

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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?

—Please choose an option—YesNo

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:

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