Group Fitness Culture Plan Proposal Request

To request a Group Fitness Culture Proposal, go to the form below and complete it. Then, click on the “Submit” button to tell us what you want. No cost. No obligation.

Our program is unique. While the health plan is the centerpiece, it is only a part of our multi-component system. Our plan can help employers and groups build a workplace Fitness Culture while promoting employee capabilities and productivity.

For group members, our advocacy and assistance programs will help you better manage your personal and family healthcare affairs in less time and at lower cost.

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

Please note that all fields followed by an asterisk must be filled in.

Name of Employer / Group:*
Name of Employer / Group:*

Indicate the total estimated number of participating employees or group members:*
Indicate the total estimated number of participating employees or group members:*

Indicate the estimated number of Employee Only Households:*
Indicate the estimated number of Employee Only Households:*

Indicate the estimated number of Employee + Spouse Households:

Indicate the estimated number of Employee + Children Households:*
Indicate the estimated number of Employee + Children Households:*

Indicate the estimated number of Employee + Spouse + Children Households:*
Indicate the estimated number of Employee + Spouse + Children Households:*

Indicate the estimated number of adults (aged 17 - 70) from all sources:*
Indicate the estimated number of adults (aged 17 - 70) from all sources:*

Indicate the estimated number of dependent minors (under 17) from all sources:*
Indicate the estimated number of dependent minors (under 17) from all sources:*

In the following name and address fields, give information for the employer/group contact person, who is an:*
In the following name and address fields, give information for the employer/group contact person, who is an:*

	Owner/Partner/Shareholder;
	Non-Owner Management Executive;
	Human Resources Official;
	Administrative Official.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Business Phone*
Business Phone*

Fax*
Fax*

MEDICAL SELF CARE PLAN: A low-cost, online information service that helps you make good decisions about your medical needs, about the appropriate use of medical services, about being an informed healthcare consumer and about managing your costs for medical services. For more information, go to the Medical Self Care Plan pages for Prevention or for Health Affairs Management.*
MEDICAL SELF CARE PLAN: A low-cost, online information service that helps you make good decisions about your medical needs, about the appropriate use of medical services, about being an informed healthcare consumer and about managing your costs for medical services. For more information, go to the Medical Self Care Plan pages for Prevention or for Health Affairs Management.*

	Yes - Include these services in my Fitness Culture Plan proposal.
	No - I do not need or want these services.

TOTAL FITNESS PLAN: A low-cost, online comprehensive and interactive personal health risk assessment and fitness program that improves health, stimulates a fitness mindset, and promotes the culture that improves your lifestyle and longevity. For more information, go to the Total Fitness Plan page:*
TOTAL FITNESS PLAN: A low-cost, online comprehensive and interactive personal health risk assessment and fitness program that improves health, stimulates a fitness mindset, and promotes the culture that improves your lifestyle and longevity. For more information, go to the Total Fitness Plan page:*

	Yes - Include these services in my Fitness Culture Plan proposal.
	No - I do not want or need these services.

PATIENT CARE PLAN (For individual and/or employee members and their immediate families): A low-cost information, advisory, assistance and advocacy service covering the healthcare system to help you better mind your healthcare affairs. Access is online or by telephone. Patient Care services will tell you what you need to know, advise you on what you need to do, help you do what needs to be done, and, if necessary, do it for you. For more information, go to the Patient Care Plan page. (Note: The focus of Medical Self Care is medical issues. The focus of Patient Care is healthcare system issues.): *
PATIENT CARE PLAN (For individual and/or employee members and their immediate families): A low-cost information, advisory, assistance and advocacy service covering the healthcare system to help you better mind your healthcare affairs. Access is online or by telephone. Patient Care services will tell you what you need to know, advise you on what you need to do, help you do what needs to be done, and, if necessary, do it for you. For more information, go to the Patient Care Plan page. (Note: The focus of Medical Self Care is medical issues. The focus of Patient Care is healthcare system issues.): *

	Yes - Include these services in my Fitness Plan proposal.
	No - I do not need or want these services.

PATIENT CARE PLAN EXTENSION (Extended services for family elders): Members who subscribe to the Patient Care Plan for themselves and their immediate family members have the option, at additional cost, to extend Patient Care Plan services to family elders for whom they have, or in the future may have, caregiver responsibilities. Patient Care services for elders include additional services that apply to caregivers and seniors. For more information, go to the Elder Care Plan page.*
PATIENT CARE PLAN EXTENSION (Extended services for family elders): Members who subscribe to the Patient Care Plan for themselves and their immediate family members have the option, at additional cost, to extend Patient Care Plan services to family elders for whom they have, or in the future may have, caregiver responsibilities. Patient Care services for elders include additional services that apply to caregivers and seniors. For more information, go to the Elder Care Plan page.*

	Yes - Include these services in my Fitness Plan proposal.
	No - I do not need or want these services.

Indicate estimated number of family elder members (age over 70) from all sources to be included:*
Indicate estimated number of family elder members (age over 70) from all sources to be included:*

Please enter the word that you see below.

Group Fitness Culture Plan Request For Proposal

Group Fitness Culture Plan
Request For Proposal