Wellness Incentive & Exam Form

If you have an appointment with your healthcare provider between May 1 and June 30, you’ll be eligible for a $50 gift card. Not only will you receive a $50 gift card, but you’ll also be entered into the overall prize drawings for a chance to win one of the following;

  1. $1,500 benefit holiday or $1,000 paid through payroll
  2. Personal Business Days – 3 days
  3. New shotgun or $250 gift card
  4. Yeti cooler with ElectriCom logo

All ElectriCom employees are eligible for this. In addition to employees, spouses carried on ElectriCom’s insurance plan are also qualified to receive a $50 gift card. Employees only will be entered into the grand prize drawings.

To be eligible to receive your gift card, you must take the attached wellness exam form to your licensed healthcare provider. Discuss the topics listed and have your provider sign off on the form. Following your appointment, please submit your form to Human Resources utilizing one of the following methods:

By mail:                                                                                                                By e-mail:
ElectriCom                                                                                                    drobbins@electricominc.com
Human Resources Benefits Department
PO Box 319                                                                                                         By Fax:
Paoli, IN 47454                                                                                                   812-723-5654

Your wellness form must be received by Human Resources no later than June 30th.

 The form to take to your health care provider can be found at the bottom of this page. Select the link and print the form. Copies were in your benefit enrollment packets, but can also be picked up at any of our office locations. 

Please make copies if your spouse will be utilizing this incentive.

 Please note; all gift cards will be distributed at the end of the incentive period, not at the time of the wellness form submission.

 If you have any questions regarding this incentive, please contact Human Resources at 812-203-3117.

Wellness Incentive Exam Form