Group and Employer Profile

Employer Factors

This Group Employer Profile page is designed to provide information for service providers to make risk assessments and to develop a proposal that meets the advice, assistance and advocacy needs of your organization and its employees. Go to the form below. Complete the questionnaire to tell us about your organization, your employees and your wants and needs. Click on the “Submit” button to send it. No cost. No obligation.

Our program is unique. While the health insurance plan is the centerpiece, our Fitness Culture program can help build a workplace wellness environment that reduces your organizational cost and responsibilities while promoting employee capabilities and productivity. It will help individuals better manage personal and family healthcare affairs in less time and at lower cost.

In addition to this form, you also need to [txtlk] Get A Quote for the type of health insurance you prefer and to complete and send us the [txtlk] Fitness Culture Plan Proposal Request.

If you have questions or need additional information, go to our Contact Us Page.

Start here . . . .

Please note that all fields followed by an asterisk must be filled in.
Name of Employer or Group:*
Address of Employer / Group (Include Street, City, County, State, & Zip Code):*
The following named person is designated as the employer / group contact person and is described as:*
Owner, Partner or Shareholder;
Non-Owner Management Executive;
Human Resources Official; or
Administrative Official.
First Name*
Last Name*
E-mail Address*
Business Phone*
Fax*
Type of Organization (Corporation, Partnership, Association, etc.):*
Federal Tax ID Number:*
Month and Year Started:*
Do you operate with multiple locations? If yes, give each location address:*
SIC Code:*
Describe Business Operations:*
Has organization ever filed bankruptcy or had lawsuits or foreclosures brought against it? If yes, please explain and give details:*
Does organization use a payroll company? If yes, name service provider:*
Does organization use employee leasing, PEO or HR outsourcing services? If yes, name service provider:*
Provide the number of full time employees and part time employees for each location and in total:*
Provide the number of people who work for you, but not on your payroll (independent contractors / 1099's / leased) if any, for each location:*
Are any employees or associates not identified in above categories? If yes, describe and give number:*
How many people in total, including owners, are employed by or associated with your business or organization? *
What is the minimum work hours per week for full time eligibility required by state law? What number is specified by your organization policy?*
How many employees exceed minimum state requirements?*
Do you have or have you applied for a group health insurance plan? If yes, give insurance company name and renewal date:*
Number of employees eligibile for current health plan coverage:*
Number of eligibile employees currently waiving coverage:*
Number of employees currently enrolled in coverage?*
Current employee coverage participation percentage:*
How much does employer contribute to premium payment for employees? For dependents?*
EMPLOYER / GROUP HEALTH PLAN REQUEST FOR PROPOSAL: Have you completed and submitted a quote request?*
Yes;
No;
In Process - Will complete and submit.
How many employees and associates woud be interested in a low-cost "pseudo group" plan paid in whole or part by employees?*
"PSEUDO GROUP" PLAN REQUEST FOR PROPOSAL: Have you completed and submitted forms for this coverage?*
How many employees and associates would be interested in low-cost "Fitness Culture Plan" support services for prevention, medical affairs management, patient care services and personal fitness training services paid in whole or in part by employees?*
GROUP FITNESS CULTURE PLAN REQUEST FOR PROPOSAL: Have you completed and submitted this request form?*
Yes;
No;
In Process - Will complete and submit.
This Employer Profile is intended to provide information designed to help you and us design a health plan and Fitness Culture program that will serve your group. You should not cancel any current health insurance coverage prior to receiving written approval of and issuance of replacement insurance. Please acknowledge your understanding of this and confirm the validity of the information offered above in this form by your electronic signature and the date signed in the space below:*

Please enter the word that you see below.

  

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