LifeStrive®Approval Request & Registration Form
Allstate Workplace Division
To ensure successful enrollment/participation, set up and planning, all requests must be submitted for approval to
LifeStrive at least 8 weeks prior to enrollment start date. Please note, our focus is Employer-paid groups of 200
lives and above.
Please submit this form to:
LifeStrive Client Services Director, Kim Clarke: email kclarke@lifestrive.com or fax to 602-296-0176
AWD: Walter Jones – email walter.jones@allstate.com
If you have questions about your request for approval, please contact Kim at 866-479-1380, ext. 7 or email
kclarke@lifestrive.com.
Request Date:
Account Name:
Group #: FORMTEXT
Account Location:
Eligible Employees:
Eligible Spouses/Dependents:
*Note: where more than one location, we require the address, zip code and number of eligible employees for
each worksite. Please submit an Excel spreadsheet with the required information.
Proposed Enrollment Start Date:
Broker of Record Name:
(Street address, City, State, Zip)
Broker of Record Contact Info:
(phone, email address)
Enrollment Firm
(Company, Street address, City, State,
Zip)
Enrollment Firm Contact Person
(Phone number, email address)
Any Related Business Development
Team
Contact Info (phone, email address)
A ) Proposed Enrolment Method:
Note: No matter the enrolment method used, accurate collection of personal email addresses, phone
numbers and zip codes are of paramount importance. Please review: Prepare for Success document.
NEW - Electronic Assignment of Benefit/E-Sign Form
All group enrolments must include an electronic assignment of benefit/e-sign process. The electronic process
eliminates the post enrolment paperwork and improves claims processing and delivery of service timeline.
Options include:
a) LifeStrive’s Electronic Assignment of Benefit/E-Sign form
 easy to use and captures all pertinent information including an electronic signature
 link can be embedded in enrolment platform
 following is a link to a demo only Electronic Assignment of Benefit form for you to test
https://www.mylifestrive.com/assignment/awd_demo_only
b) Electronic Enrolment Platform
 includes AWD approved assignment of benefit process which includes a electronic signature component
(eg. Benefit Select)
 accurate collection of personal email addresses, phone numbers and zip codes are of paramount
importance (these fields must be presented as mandatory)
Please indicate below the proposed enrolment method:
Company Direct – where company provides a completed employee census, which includes worksite location
details (required for scheduling lab testing) and personal emails to ensure direct seamless communication.
Electronic Enrollment – requires screenshots and/or flash presentations made available to enrolment partner,
One-on-One Enrollment – requires print materials and facilitation of gathering employee contact information.
Call Center Enrollment – requires scripting and obtaining of full contact information
Other:
B) Product Positioning
Please confirm that LifeStrive has been presented as an employer-paid health promotion/wellness initiative
with prepaid lab testing and personal health portals, where a Voluntary Benefit includes a $100 wellness rider,
which is being used to fund all or part of the LifeStrive fees.
Confirmed
What are the participation incentives? Please describe:
(Important Note: “Participation” must be clearly defined and criteria established in order for LifeStrive to
ensure tacking and reporting on reward qualifications.)
C) Wellness Benefit Rider Options: (indicate preferred option)
Wellness benefit rider will be assigned back to employer to recover substantial portion of their investment
in LifeStrive. Please describe:
The employee is permitted to submit their LifeStrive lab testing to claim the $100 benefit personally, as an
added incentive to participate. Please describe:
You are applying for LifeStrive to accept the assignment of benefit as payment for services.
(Strict criteria are applied to this last option.)