Request for Proposal


	Company Name Company Industry Contact Person(s) Location(s) Number of Employees We are a: Corporation Union Association Member Organization Bank/Credit Union Other Address City, State, Zip Phone Number Fax Number Email Address Website Best Time to Reach You: Requesting a Proposal for (Please check all that apply): Cancer Insurance Critical Illness Insurance Accident Insurance Disability Insurance Life Insurance Wellness Program KiND Walk Dental/Eye/RX Discount Program Do you currently have a Wellness Program? Yes No Please choose for Group Wellness Program Quote: Core Program (Website Only) Core Plus (Core Program + Pedometer Program) Enhanced Core (Core Plus + Challenges Program) Premium Program If You Selected "Premium Program" above, please check all that apply: Biometrics Screenings Onsite Preventative Screenings Onsite Speakers (Lunch & Learns) Onsite Health Coaches Vaccination Clinics Onsite Chair Massages Annual Health Fair Onsite Presentation Yes No Special Requests or Interests How did you hear about us? Who Referred You? Representative/Broker Name: Enter the message as it's shown* Should be Empty: