Healthy Living Membership Employer Application

How did you hear about us?*

If you were referred by someone, please provide a name so we can say 'thank you'.

Internet search
Wellness provider
Email campaign

Business Information

Name of Business*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Owner, General Manager, or Managing Partner*

First Last

Primary Contact for this program (if different)

First Last

Email*

Phone*

Business Tax Identification Number*

Plan Design - what you'll offer employees

Select your plan design*

LEARN IT only (voluntary) - $16 PEPM
LEARN IT only (employer paid) - $12 PEPM
LEARN + PLAN IT (1 consult) - $537 PEPY
LEARN + PLAN IT (4 consults) - $399 PEPQ
LEARN + DO IT
Complete plan: LEARN, PLAN & DO

What point levels are you offering? (LD)

Select All
10 pts per month - $158 PEPM
20 pts per month - $302 PEPM
30 pts per month - $447 PEPM
Contact us for custom amount

What point levels are you offering? (LPD)

Select All
5 pts per month - $206 PEPM
10 pts per month - $283 PEPM
15 pts per month - $359 PEPM
20 pts per month - $436 PEPM
Contact us for custom amount

Plan Set-Up

Start Date / Renewal Date*

Start Date Renewal Date

Check one:*

Employer pays 100% of the plan cost
Employer and employee share in the plan cost
100% Voluntary - all options are available to employees

# of Eligible Employees*

Enrollment Method*

Online (a link will be set up for you)
Paper application
Spreadsheet (attach in next step)

Employee census in lieu of individual applications (optional)

Accepted file types: xls, xlsx, Max. file size: 200 MB.

We will need the following information in separate columns: First Name, Last Name, Email Address. Email address is required for communicating with employees about their benefit and they will never be spammed. If email addresses are unavailable or not issued to employees, please contact us for other options.

Acceptance

We hereby agree to offer the Healthy Living & Wellbeing Plan from You Define Wellness (YDW) for the benefit of our employees. The YDW plan may consist of Individual Wellbeing Assessments with one-on-one coaching sessions with a YDW certified Wellness Pathfinder, wellness sessions per enrolled employee, and wellness education classes for enrolled employees all as indicated above as long as our account is in good standing. We understand other benefits may also be available to us upon request.

We agree to remit to YDW the membership fee for all enrolled employees prior to the 1st of each month; all paid benefits are available to employees as of the 1st of each month after payment has been received by YDW. We understand that failure to remit payment in a timely manner may suspend or terminate services for employees. We understand provider payment for services received by enrolled employees will not be advanced by YDW awaiting payment from us.

We agree that this program will remain in effect for one year from the program start date and will automatically continue as of the renewal date indicated above and all subsequent years until terminated in writing by us. We understand that the rates stated in this Agreement are valid for the initial plan year only; the rate may be adjusted by YDW prior to subsequent plan years.

We understand this program is not insurance and is not subject to COBRA or State Continuation but have the right to offer it as a benefit to former employees in accordance to our internal applicable procedures. We understand it is our responsibility to notify YDW of terminated employees.

We acknowledge that the YDW program has been explained in full, that YDW is not an insurance program nor is it a replacement for traditional medical insurance, and we fully accept and subscribe to all the terms and conditions contained in this Agreement.

Accepted by:*

First Last Title

NOTE: Online payments are processed through O'MALLEY & ASSOCIATES, LLC (our parent company) via a secure connection with PayPal.

Healthy Living Membership Employer Application

Employer Application - Customization

Business Information

Plan Design - what you'll offer employees

Plan Set-Up

Acceptance

Important Info

Contact Us!

Join Our Network

Join Our Sales Team

Toolbox for Network Providers