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    Amaze Account Application

    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.
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    What is Your Role?(Required)

    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.
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    This is the name of your company as it should appear on documents for billing purposes and credit card or ACH authorizations.
    The name of your company as generally known to employees.
    Billing Address(Required)
    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.
    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)
    MM slash DD slash YYYY
    If not using SFTP/Sharefile, please attach the 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. Employee Census Template
    Drop files here or
    Max. file size: 1 GB.
      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.
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        How would you like to manage ongoing enrollments?

        Points of Contact

        Please let us know who our main point(s) of contact will be at your company.
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        Third Party Name(Required)
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        Enrollment / HR Contact(Required)
        Is there a different point of contact for Billing?(Required)
        Billing Contact(Required)
        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
        eMail
         

        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 with effect at the end of the current month. Any adjustments made for non-timely employee terminations shall be credited the following month.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.
        Click Link for Member Terms & Conditions
        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.

        To Pay By Credit Card

        Please use the following link: Amaze Health GoCardless
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        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.

        Education Preference

        We highly recommend scheduling a kickoff call with a member of of account management team to discuss employee education.
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        Would you like to schedule a kickoff call for your client?(Required)
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        Would you like to schedule a dedicated webinar session for employee education?(Required)
        Would you like any education resources to provide to employees?
        Does anyone on your team require Spanish accommodations for communications?
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