Full Company Name *

Company Address *

First Name *

Last Name *

Phone *

Email *

1: Number of Employees Needing Eyewear *

2: Eyewear Distribution Locations *

3: Type(s) of Eyewear Required *

Prescription

Non-Prescription

Both

4: Side Shields Requirement *

Yes, required for all eyewear

No, not needed

Only required for certain job roles

5: Preferred Type of Side Shields *

Permanent side shields

Detachable side shields

Clip-on side shields

Wraparound-style frames (integrated protection)

6: Eyewear Benefit Structure *

Fixed dollar amount per employee (e.g., $200/year)

One pair per year (company-paid)

One pair every two years

Other

7: If Applicable, Enter Budget or Allowance Details *

8: Benefit Cycle Start and End Dates (Please specify the start and end dates of your employee eyewear benefit cycle (e.g. Jan 1 – Dec 31).

9: Are any lens coatings or treatments required? *

Yes

No

Not Sure Yet

17: Let us know what reporting features you'd like to track eyewear program usage and spending *

Monthly usage reports (number of orders, active users, etc.)

Cost breakdown by department or location

18: Support Contact Preferences *

Live Chat

Phone

Email

All of the them