ROI Form

Company Name

First Name

Last Name

Email address

1. Number of full time employees in your company?

How many are covered on health plan?

If multi state, please provide breakdown by state:

Insurance Platform

Fully insured? Self-funded?

Carrier?

Total medical claims for the most recent 12 months:

Total RX claims for the most recent 12 months:

Preemployment screenings used?

Yes No