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2021 Employer Member Application
Primary Contact Information
*
Company Name
*
First Name
*
Last Name
*
Title
*
Employer Email (ONLY)
Best Contact Number
*
Mailing Address 1
Mailing Address 2
*
City
*
State
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*
Zip
Employer Demographics
Corporate Website
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Total Number of U.S. Employees
<500 Employees
500 - 1999 Employees
2000 - 9999 Employees
10,000 Employees
*
Number of Houston employees
Please provide an exact number or best estimate as possible.
Current Health Plan
--Please select--
Aetna
Blue Cross Blue Shield
Cigna
Kelsey
Memorial Hermann Health Plan
Multi Plan
United Healthcare
WellCare
Other
Other Health Plan Name:
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Health Plan Primary Contact Name
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Health Plan Primary Contact Email
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PBM
--Please select--
CVS Caremark
Express Scripts
OptumRX
Walgreens
Cigna
Willis Towers Watson
Other
Other PBM Name:
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PBM Primary Contact Name
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PBM Primary Contact Email
Broker/Consultant
--Please select--
Alliant
Aon
Gallagher
Mercer
Marsh Wortham
USI
Willis Towers Watson
Lockton Dunning
Marsh & McLennan
BXS Insurance
Other
Other Broker/Consultant Name:
*
Broker / Consultant Primary Contact Name
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Broker / Consultant Primary Contact Email
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