Preventive Screening Verification
Use this form to submit proof that you have completed your preventive care screening.
Employee First Name
*
Employee Last Name
*
Employee Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee Email
*
example@example.com
Employee Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
EXPLANATION OF BENEFITS FOR PREVENTIVE EXAM REQUIRED BELOW
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
By signing below, I understand that it is a crime to knowingly provide false, incomplete, or misleading information for the purpose of defrauding the company for insurance purposes. Penalties may include imprisonment, fines, termination, or a denial of insurance benefits. We would also be liable for any reimbursement of any reward or discount provided by ESCWR on our behalf.
*
Submit
Should be Empty: