COVID-19 Vaccine Interest Form For Employer Groups

Pinnacle Claims Management, part of the Western Growers Family of Companies (WGFC), is planning to administer the COVID-19 vaccine to health plan members’ employees. We will be offering onsite vaccinations to our health plan groups, as well as vaccinations at our Cedar Health and Wellness Centers located throughout California: Oxnard, Salinas, Santa Maria, and Watsonville.

As we prepare for distribution of the vaccine, we would like to gather information that will enable us to provide our health plan members with an efficient process when the vaccine becomes available to us.

* If you are an employer interested in providing vaccinations for your employees, please fill out this form. Please note this is not a form for individuals to schedule a vaccination.

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* Filling out this form does not guarantee that your organization will receive the vaccine. Once we receive the vaccine, we will use this information and work with you to schedule vaccinations for your employees.

Contact Name

Company Name

Corporate Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

COVID-19 Vaccine Interest Form For Employer Groups

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* Filling out this form does not guarantee that your organization will receive the vaccine. Once we receive the vaccine, we will use this information and work with you to schedule vaccinations for your employees.

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* Estimated # of employees interested in receiving the vaccine

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* Comments