2. 
3. Employee Last Name*
4. First Name*
6. New or Existing MAPS member*

   1. New member for 2020
   2. New Hire
   3. 2019 Member
7. Current Employee or Retired*

   1. Current Employee
   2. Retired Employee
9. Department*
10. Union/ Non-Union*

    1. UMWA
    2. WCCREA
    3. SEIU
    4. Park Police
    5. Children's Bureau
    6. Detectives
    7. District Attorney
    8. WCAPE
    9. Non-Union
12. Phone*
13. Email
15. Healthcare Provider*

    1. UPMC

    1. Highmark
16. Member ID (on front of card)
18. Upload Wellness Qualification Verification Form
    Upload paper Wellness Qualification Verification Form for 2020.
20. Upload Supporting Documentation for Wellness Qualifiers
    Suggestion: You may still want to upload your verification document. This will eliminate any required steps if you fall within the audit. Please do not submit and private health information.
22. Will you be entering applicable spouse information?*

    1. Yes

    1. No
24. Spouse Name*
    First and Last Name
26. Upload Wellness Qualification Verification Form
    Upload paper Wellness Qualification Verification form for 2020 with spousal information.
28. Upload Supporting Documentation
    Suggestion: You may still want to upload your verification document. This will eliminate any required steps if you fall within the audit. Please do not submit and private health information.
30. Additional Upload
    This file upload can be used if an additional is needed.
32. Your electronic signature below indicates your agreement with the following statements: By typing my name in the following box and clicking the submit button, I certify the above statements to be true and correct to the best of my knowledge, information and belief.
34. I authorize the information to be used for the purpose of processing my MAPS qualification on a one time basis.
36. I understand that my Wellness Medical and Activity Verification form can only be submitted one time and that multiple submissions will not be accepted.
38. I understand that any false statements, omissions, or inaccuracies on the Wellness Medical and Activity Verification Form shall disqualify me and my dependents from MAPS qualification for this year and subject me and my dependents to mandatory audit for the following qualifying year.
40. I further understand that the responses submitted are subject to random audit by Human Resources and that I will cooperate and provide verification of my responses as requested by Human Resources. Failure to comply with the audit requirements shall disqualify me and my dependents from MAPS qualification.
42. I further understand that any audit, revealing false statements, omissions or inaccuracies, shall be placed within my personnel file.
44. Employee Signature*
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field