Sponsorship Request Form

Organization Information

Contact First Name

Contact Last Name

Job Title

Company/Organization

Address

ZIP

City

State

Email Confirm Email

Select the category that best describes the mission of your organization

Arts & culture

Education

Health

Human services

Sporting event/sports marketing

Professional trade organization

Other

Specify other mission

Opportunity or Event Details

Name of Opportunity/Event

Opportunity/Event Website

Specify the Iowa or South Dakota geographic focus of your opportunity/event

Western Iowa

Central Iowa

Eastern Iowa

Western South Dakota

Eastern South Dakota

City of Opportunity/Event

State of Opportunity/Event

Start Date of Opportunity/Event

End Date of Opportunity/Event

Deadline for Inclusion

Briefly describe your opportunity or event, and list the goals and objectives

Select the category that best describes the focus of your opportunity or event

Nonprofit/charity fundraiser

Program or ongoing initiative

Festival, fair or non-sporting event

Performing arts and entertainment

Sporting events/sports marketing

Professional trade organization

Other

Specify other focus

Select the element of well-being your opportunity or event most directly supports

Physical

Career

Financial

Social

Community

Emotional

Learn more about the six elements of well-being from Blue@Work by Wellmark.

What type of support are you requesting?

Monetary sponsorship/contribution

Donation of product or service

Other

Specify other type of support

Specify amount or product/service requested

Is a Wellmark employee actively involved with your organization, opportunity or event?

Yes

Name(s) of the Wellmark employee(s) involved

Job Title(s) of the Wellmark employee(s) involved

Have you engaged or solicited support from any other health insurer?

Yes

Is your organization designated by the IRS as a 501(c)(3) not-for-profit?

Yes

By submitting a sponsorship request, I give my consent for Wellmark to contact me.