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Complete your wellness activity and submit this form by October 1, 2018.

© 2017 Sysco | LEGAL | PRIVACY

"I Got My Screening at a Non-Quest location" Form

WAIT! You and your spouse will need to include the last four digits of your (the associate's) Social Security number and date of birth with each form submission.

By clicking “START” below and “Submit” on the following form, I certify that the information I provide is true and accurate to the best of my knowledge. I understand that if I provide false information, Sysco has the right to cancel my 2019 Wellness Reward without notice, and any prior reward amounts already received will be retroactively denied. If this occurs, the medical plan premium reductions that have already been received will be recouped by the Company via future payroll deductions, where permitted by law. Or, the reward amount already deposited in my healthcare expense account will either be reduced to zero or in some cases recouped by the Company via a payroll deduction, where permitted by law. I also understand that falsifying information is grounds for disciplinary action, up to and including termination of the associate’s employment with Sysco.

By clicking “START” below and “Submit” on the following form, I agree to provide additional information and cooperate with an audit of this data, if requested by HR and understand that I may not be eligible to receive the 2019 Wellness Reward if I fail to do so. I consent to a Plan representative contacting the provider, if needed, to confirm the wellness activity (biometric screening at a Non-Quest Diagnostics location) occurred in the required timeframe.

By clicking “START” below and “Submit” on the following form, I understand that it is my responsibility to print or otherwise write down the reference number displayed that shows I have submitted this form. If I do not print or document the reference number, I cannot assume that the “I Got My Screening at a Non-Quest Location” form has been completed and I may be ineligible to receive the reward.

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