Employer Questionnaire Form

Does your company currently offer onsite health care services to employees?

No Yes

Are your health care services provided by a 3rd party vendor or managed in-house?

Third Party Direct through my company

What health care provider are you currently working with?

Why are you looking to make a switch?

What do you like about your current onsite health care services?

How many health center locations are you planning to open? *

Estimate # of employees at this location: *

Select this state where of this location: *

Estimate # of employees at 2nd location:

Select this state where of 2nd location:

Estimate # of employees at 3rd location:

Select this state where of 3rd location:

Estimate # of employees at 4th location:

Select this state where of 4th location:

Estimate # of employees at 5th location:

Select this state where of 5th location:

Estimate # of employees at 6th location:

Select this state where of 6th location:

Estimate # of employees at 7th location:

Select this state where of 7th location:

Estimate # of employees at 8th location:

Select this state where of 8th location:

Estimate # of employees at 9th location:

Select this state where of 9th location:

Estimate # of employees at 10th location:

Select this state where of 10th location:

Will spouses and dependents be eligible to use the health center as well?

Yes No

Select the onsite health services you are interested in:

Select the employee wellness services you are interested in:

Biometric Screening Wellness Coaching Fitness Nutrition Incentive Programs Wellness Portal

What are your main initiatives for offering on-site health care? (select all that apply)

Better manage overall health spend Reduce member health risk Reduce absenteeism / increase presenteeism Increase employee productivity Manage chronic conditions Improve quality of care Attract and retain top talent Reduce/manage workplace injuries Other

If other, please explain:

When are you planning to select an onsite health care vendor?

Are you working with a consultant or broker?

Yes No

Name of consultant/broker (optional):

Your Name *

First Name Last Name

Job Title

Company *

Phone Number

Area Code Phone Number

Email *

example@example.com

Employer Questionnaire

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