Member Companies | Join the Coalition

 

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Use the form below to submit your application to become a member of the Lehigh Valley Business Coalition on Health Care.

Your Information (* = required.)
First Name *
Last Name *
Email Address *
Broker Name *
Business Name *
Work Information
Street Address *
Apt, PO Box, Suite etc.
City *
State/Region *
Zip + 4 *
Country
Number of regular full-time employees, as of the end of the applicant’s immediately preceding fiscal year:
# employees in LVBCHC service area: *
# employees not in service area enrolled in the program: *
counties in primary service area
Lehigh Northampton
Berks Bucks
Carbon Schuylkill
Warren, NJ
CEO Name *
CEO telephone *
CEO fax number *
CEO email address *
Employee Benefits Representative *
EBR telephone *
EBR email address *
EBR fax number *
Note:
If elected to membership, we hereby accept and agree to be bound by the Articles of Incorporation and Bylaws of the Lehigh Valley Business Coalition on Health Care as now in effect or hereafter amended. In addition, we understand that the chief executive officer or other designated officer of the applicant is expected to represent the applicant at meetings of the Board of Directors and committees of the Board. We also understand that the principal benefits officer or employee of the applicant and other representatives of the applicant will be called upon to assist in the activities of the Business Coalition, such as Board Representative or Committee Member.
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Lehigh Valley Business Coalition on Health Care
60 West Broad Street, Suite 105, Bethlehem, PA 18018
Phone (610) 317-0130 | Fax (610) 317-0142

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