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CREATING AN ENVIRONMENT FOR CONTINUOUS IMPROVEMENT IN THE COST AND QUALITY OF HEALTHCARE
General Information
 
Membership Application
  • If you are interested in joining as a EHCO 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 and retirees that are converd by your medical benefits plan for your entire company:
Number of employees and retirees that are covered under your medical benefits program in Ohio:
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)