Date of Application

Membership Effective Date

Company Name ("Prospective Member")

Address

City

State / Province Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon

Primary Contact (first name)

Primary Contact (last name)

Title

Email If you do not have an employer-based email address please email Emily Clevenger at eclevenger@employershealthco.com for assistance.

Phone

Total number of eligible employees and/or retirees Please note: Member organizations participating in group purchasing will be billed at a minimum of 100 employees.

Employers Health Group Purchasing Program Participation CVSOptumRxElixir

Employers Health Ancillary Vendor Program Participation EyeMedComPsychDeltaDental

Membership Category Sustaining: All privately held and/or publicly traded organizations, other than those that meet the criteria of an Affiliate, Contributor or Labor Union, as defined in the Employers Health by-laws and described below.Affiliate: Governmental (school districts, municipalities, counties) and other not-for-profit organizations domiciled in Ohio excluding those that fall into the Contributor category.Contributor: Managed care organizations, health care providers (hospitals, physician groups), TPAs, consultants, brokers and pharmaceutical manufacturers who do not participate in an EHPC program.Labor Unions (e.g. Taft-Hartley health and welfare funds, VEBA Trusts).Participating Group: An organization participating in Employers Health group purchasing programs through its membership or strategic relationship with an Employers Health Strategic Affiliate. Please consult your Employers Health representative prior to selecting Membership Category.

Affiliate Name (If applicable)

Applicant First Name

Applicant Last Name

Title

App Signature Date

Comments

By submitting this application and subject to approval of Prospective Member’s membership by the
Employers Health Coalition, Inc. (EHCI) Board of Directors, Prospective Member agrees to all of the following:

1. Prospective Member will pay all properly invoiced annual membership dues as set forth in the EHCI bylaws, as amended; and
2. Prospective Member’s membership will automatically renew for successive one year terms beginning on the effective date anniversary, unless terminated in writing by EHCI or Prospective Member thirty days before renewal.