Pathways Employer Application

Are you ready to get started with Pathways: a multidimensional Wellness@Work Option? Complete the application below.

Download a copy of the Employer Application

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
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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*
Check one:*
- Employer pays 100% of the plan cost
- Employer and employee share in the plan cost
# 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.
Start Date / Renewal Date*
Start Date Renewal Date
ACCEPTANCE
We hereby agree to offer the You Define Wellness (YDW) PATHWAYS: WELLNESS@WORK for the benefit of our employees. The YDW plan consists of two bi-annual Individual Wellbeing Assessments, four quarterly one-on-one coaching sessions with a YDW certified Wellness Pathfinder, one wellness session per enrolled employee that must be used within 90 days of activation, and one wellness education class for enrolled employees monthly unless customization has been requested for 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 wellness program fee for all enrolled employees prior to the 1st of each month that activates new employee wellness sessions; all paid benefits are available to employees as of the 1st of each month as long as 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 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 our account will be credited with one-half the value ($60 value, $30 credit) of unused and expired session values within 30 days of said session expiration. The remaining one-half of unused and expired session values will help support non-profit healing partners in the community. If a qualified non-profit organization is not indicated below, we agree YDW will designate the recipient organization.
Employer designated non-profit organization to support:
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.

Pathways Employer Application Denise January 31, 2021

Pathways Employer Application

Employer Application

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