Membership Application Form For Employers

LVBCH Employer Application Form – To join the Lehigh Valley Business Coalition on Healthcare (LVBCH) as an employer member whose employees will be eligible to enroll in LVBCH programs (i.e., medical, dental, vision, Rx drug, etc.), please complete the following information about your organization. Send the completed application form via email to LVBCH@LVBCH.com. Upon receipt of your application, we will send you an invoice for your annual dues. If you have questions, please contact us.

Please complete all fields on this application. Use the tab key on your keyboard to advance to each field.

Applicant’s Business Name:

Is this Business a subsidiary of another corporation? Yes	No

If Yes, enter the name of the Parent Corporation:

If Yes, do you want to join without your Parent Corporation becoming a member: Yes	No

Applicant’s Business Billing Address:

Applicant’s Business Website Address:

Description of Applicant’s Primary Business:

Primary Contact Representative Name & Contact Information:

Contact Name:

Contact Title:

Contact Email:

Contact Phone:	Contact Fax:

Mailing Address:

Number of regular full-time employees at the end of the applicant’s immediately preceding fiscal year:

a.	Number (#) of employees who work in PA
b.	# of employees who do NOT work in PA but who will be enrolled in an LVBCH program
c.	Total # of employees

Please answer the following Yes/No questions about your business:

Yes	No	Is your business headquartered in PA?

Yes	No	Is your business non-profit or tax-supported (i.e., school, municipality, college, etc.)?

Yes	No	Is your business a healthcare provider, pharmaceutical, broker or insurance company?

Yes	No	Is your business self-insured for medical coverage?

Please provide the following Benefits-related information about your “Active” employee population:

Company Name of Broker/Consultant:

Company Providing Medical Benefits:

Company Providing Dental Benefits:

Company Providing Vision Benefits:

Company Providing Rx Drug Benefits:

www.LVBCH.com 60 West Broad St., Suite 105, Bethlehem, PA 18018 email: LVBCH@LVBCH.com Phone: 610-317-0130 Fax: 610-317-0142

The undersigned hereby applies for membership in LVBCH on behalf of the Business listed above.

If approved for membership, we hereby accept and agree to abide by the Articles of Incorporation, Bylaws and policies of LVBCH as now in effect or hereafter amended. Entering your name in the field below will act as your digital signature.

Name:	Title:	Date: