Date of Application
Membership Effective Date
Company Name ("Prospective Member")
State / Province
District Of Columbia
Prince Edward Island
Primary Contact (first name)
Primary Contact (last name)
If you do not have an employer-based email address please email Emily Clevenger at email@example.com for assistance.
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
Employers Health Ancillary Vendor Program Participation
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.
Applicant First Name
Applicant Last Name
App Signature Date
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: