Membership Application

If you are interested in joining as a Sustaining, Affiliate, Small Business, or Contributor Member, fill out the form online below.
You may return your completed application via fax at 330.305.9055. The Board of Directors meets on the fourth Tuesday of every month to approve new members.
If you are out of state, please call Mike Stull at 330.639.2281 for the appropriate membership materials.

Membership Application Online Form

Date of Application

Participation Effective Date:

Company Name:

Subsidaries / Parent Company :

Address :

Web Address :

Phone :

Fax :

Name of CEO :

Name of CFO :

Type of Business :

Primary Contact Name :

Title :

Email :

Phone :

Fax :

Secondary Contact Name :

Title :

Email :

Phone :

Fax :

Total number of employees that are converd by your medical benefits plan for your entire company:

Number of employees that are eligible to be covered under your medical benefits program:

Are bargaining unit employees covered under your plan?

Number of employees under a collective bargaining unit.

What employee benefit programs do you currently offer? Please list the vendor for each program.
	HMO	PPO	POS	Indemnity
	Vision	Dental	Long-Term Care	Wellness Program
	Behavioral Health Network / EAP		Prescription Drug Converage
	Other

When is your renewal?

What is your company's health and wellness strategy?

Do you provide retiree coverage?

Yes No

If YES, for how many retirees company wide?

How many retirees in Ohio?

Is your Health Plan

Name of Third Party Administratior/Insurance Carrier who presently administers your core health plan:

Please list the health plans you offer and the number of employees in each plan :

Plan Name

Number of Employees

Plan Name

Number of Employees

Plan Name

Number of Employees

	Sustaining Member (Annual Membership Dues: $4.50 per Ohio employee subject to a maximum of $12,000)		Affiliate Member Applicants (Annual Membership Dues: $750)
	Small Business Member Applicants (Annual Membership Dues: $200)		Contributor Member Applicants (Annual Membership Dues: $1000)