BECOME A CLIENT - LifeAssist

Client

Your Name

Designation

Email Address

Organisation Website:

Contact Number:

Alternate Contact Number

Physical Address:

City:

Province:

Market Sector:

Number of Worksites:

Locations of Worksites:

About your staff

Please complete as much information as you have available about your staff

No. of Staff

Average no. of Dependents

Demographic % Est. Management

Demographic % Est. Employees

Heathcare Insurer:

Company appointed Individual selection

If company selected, please provide supplier:

Retirement Fund:

Company appointed Individual selection

If company selected, please provide supplier:

Disability Insurer:

Existing or Previous Services

Organisation:

Engagement Utilisation Rate:

Contract Term/Notice period:

Scope and Objectives:

of your Employee Wellbeing Programme

Thank you:

Thank you for taking the time to complete this form. We will be able to get back to you with a more accurate proposal. Please feel free to call us to discuss your needs!

Any additional information:

Proposed Presentation Date: