Amaze Health Subscription Agreement

Amaze New Client Registration

This is a secure form. Upon completing this application, you will be contacted by your Amaze account manager. No billing will occur until after your employees are enrolled in Amaze. You and your account manager will agree upon the timing and the best way to educate your team on how to get the most value from their relationship with Amaze.

What is Your Role?(Required)

I am a representative for the company

I am a third-party representing the company

Company Details

This Subscription Agreement is hereby entered into by and between Amaze Health, a Delaware Public Benefit Corporation with a mailing address of PO Box 329, Longmont, CO, 80502 and the Company designated below.

Referred by:(Required)

Please tell us the name of the individual who referred you to Amaze.

Referring Organization(Required)

Please let us know the name of any organization you have been referred by. This may be an association, religious organization, chamber of commerce, insurance agency, trade union, medical office or other type of organization. Just indicate "none" if this does not apply.

Company Name(Required)

This is the name of your company as it should appear on documents for billing purposes and credit card or ACH authorizations.

Company Nickname

The name of your company as generally known to employees.

Company Website (if you have one)

Billing Address(Required)

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

Physical Address of Primary Point of Business (if different from billing address)

This is your headquarters or principal place of business. Additional locations can be added below.

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

Other Locations

As best you can, please list any other significant places of business. Click the plus sign to add additional locations.

Location Name

City, State

Approximate Number of Employees

Which Employees will be Enrolled?(Required)

All Full-Time Employees

Only Employees Enrolled in Our Medical Plan(s)

Other

If Other, Please Explain:

Approximate Number of Employees to be Enrolled(Required)

Anticipated Start Date(Required)

Employee / Member Census

THIS IS A SECURE UPLOAD. If not using SFTP/Sharefile, please attach an employee census to be used for enrollment. Be sure to include the first name, last name, gender, date of birth, preferred email address, mobile phone number, SSN, state of residence and zip code for each eligible employee. *SSNs is a requirement. Members will add their family members to their account after their account is created. Employee Census Template

Drop files here or

Max. file size: 1 GB.

Plan Documents

Please attach the most up to date plan documents for this group (includes Benefit Guide, Summary of Benefits, Dental/Vision, HSA, HRA, HealthPerks, prescription plans, etc.). If this is not available, please provide this information as soon as possible.

Drop files here or

Max. file size: 1 GB.

Plan Funding Type

Self-Funded

Level-Funded

Fully Insured

Insurance Carrier

Third Party Administrator

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How would you like to manage ongoing enrollments?

Amaze Client Portal

File Feed

Points of Contact

Please let us know who our main point(s) of contact will be at your company.

Third Party Name(Required)

First Last

Third Party Affiliation(Required)

Third Party Phone(Required)

Third Party Email(Required)

Enrollment / HR Contact(Required)

First Last

Title(Required)

Phone(Required)

Email(Required)

Is there a different point of contact for Billing?(Required)

Yes, different point of contact

No, same person

Billing Contact(Required)

First Last

Email(Required)

Phone(Required)

Agency Name

Agency Contact

First Last

Agent Email

Agent Phone Number

Other Points of Contact

Please add anyone else that we should get to know. This can be members of your leadership team, members of your HR or finance department, and anyone else that comes to mind. Just click the plus sign to add additional people.

First Name

Last Name

Title, Position or Role

Phone

Terms & Payment Details

Company Terms(Required)

Company is billed for the month in which it begins services, regardless of the actual start date for services (i.e., it is a monthly billing cycle, which starts on the first day of the month and ends on the last day of the month). Billing occurs on or about the 5th day of each month. Company may cancel at any time by providing Amaze with 30 days notice, however, the subscription fee is non-cancelable and non-refundable. Company may add employees or remove them from Amaze’s system at any time, but to ensure proper billing, all such changes must be communicated to Amaze no later than the last day of the current month. If there are exceptional circumstances which prevent such timely notice, any required adjustments will be made in the form of a credit in the following month. Similarly, if after review, there was an under or over charge, any required adjustments will be applied to the next billing cycle.Please check the box below to acknowledge Amaze's billing terms.Below is also a link to the online agreement accepted by each employee and their adult family members upon their first login to Amaze.

Approved

Client Terms and Conditions

These are the company terms we will send to the client: "Company is billed for the month in which it begins services, regardless of the actual start date for services (i.e., it is a monthly billing cycle, which starts on the first day of the month and ends on the last day of the month). Billing occurs on or about the 5th day of each month. Company may cancel at any time by providing Amaze with 30 days notice, however, the subscription fee is non-cancelable and non-refundable. Company may add employees or remove them from Amaze’s system at any time, but to ensure proper billing, all such changes must be communicated to Amaze no later than the last day of the current month. If there are exceptional circumstances which prevent such timely notice, any required adjustments will be made in the form of a credit in the following month. Similarly, if after review, there was an under or over charge, any required adjustments will be applied to the next billing cycle.Please check the box below to acknowledge Amaze's billing terms.Below is also a link to the online agreement accepted by each employee and their adult family members upon their first login to Amaze."

Approved to Send to Enrollment/HR Contact

Click Here for Member Terms & Conditions

Please fill our GoCardless to set up auto payment

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Please indicate how you would like to be billed.(Required)

No billing will occur until after Amaze receives your employee details and enrolls your employees. Your account manager will be in touch to make a plan.

GoCardless

Credit Card

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To Pay By Credit Card

Credit Card Number (16 Digits)

Expiration Date (MM/YYYY)

Security Code (3 Digit SEC, 4 for AMEX)

Please use the following link: Amaze Health GoCardless

This field is hidden when viewing the form

To Pay By Auto Debit (ACH)

Additionally, I/we authorize that such account exists and that the Financial Institution is capable of crediting and/or debiting such entries initiated by AMAZE HEALTH without responsibility for correctness of such amounts. I/we have verified account number and the Financial Institution’s routing number to AMAZE HEALTH.

Routing Number

Bank Name

Account Number

Education Preference

We highly recommend scheduling a kickoff call with a member of our account management team to discuss employee education.

Would you like to schedule a kickoff call?(Required)

Yes

Please provide 3 dates and times for a kickoff call:

Would you like to schedule a dedicated webinar session for employee education?(Required)

Yes

Please provide 3 dates and times for an employee education session:

Would you like any education resources to provide to employees?

Pre-recorded webinar

Internal announcement template

One-page flyer

Does anyone on your team require Spanish accommodations for communications?

Yes