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

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

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

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

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

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

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

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

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* 9. 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?

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