Designed Wellness Premier Request to Join Form

This form is intended for firms that would like to implement the Designed Wellness Premier Plan at their next medical plan renewal. Please complete the below questions and a representative from ACEC Life/Health Trust will contact you regarding your submission. If you have questions or need more information about Designed Wellness, please email lindsay@aceclht.com.

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* 1. Please enter the name of your firm.

Firm Name

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* 2. Does your firm agree to identifying a member of upper management to be involved in supporting the Designed Wellness program objectives?

Yes

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* 3. Please enter name and contact information of that upper management individual.

Name

Email Address

Phone Number

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* 4. How will upper management support the Designed Wellness program objectives? (check all that apply)

Align the wellness program objectives with the company’s mission/vision.

Check in with internal program administrator on status of program and assist with strategic planning.

“Walk the Talk” by participating in the wellness program and complete required activities.

Communicate to employees the importance of a wellness program for measuring and improving health.

Be involved in the program rollout.

Remind employees and spouses to use available wellness resources.

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* 5. Does your firm agree to identifying a program administrator/Wellness Champion for the Designed Wellness Premier Plan?

Yes

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* 6. Please enter name and contact information of the individual that will serve as the Wellness Champion for your firm.

Name

Email Address

Phone Number

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* 7. How many years has your firm had a workplace wellness program?

5 or more years

3 - 4 years

1 - 2 years

Never have implemented a workplace wellness program

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* 8. What workplace wellness programs have you participated in?

Simply Engaged through United Healthcare

Program offered by another insurance carrier

Program our firm created internally

Other (please specify)

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* 9. Does your firm have office locations that could guarantee 30 participants for an onsite screening event?

Yes

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* 10. In order to continue participating in the Designed Wellness Premier Plan, a firm must maintain at least a 10% engagement rate. Engagement is defined as number of employees/spouses that have completed the health assessment and biometric screening divided by the total number of eligible employees/spouses. Failure to maintain 10% engagement will result in the firm being moved to the Basic Plan at the next medical renewal. Does your firm agree to meet the 10% engagement rate?

Yes