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2021 Employer Member Application

* Company Name

* First Name

* Last Name

* Title

* Employer Email (ONLY)

Best Contact Number

* Mailing Address 1

Mailing Address 2

* City

* State

* Zip

Corporate Website

* 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

Other Health Plan Name:

* Health Plan Primary Contact Name

* Health Plan Primary Contact Email

* PBM

Other PBM Name:

* PBM Primary Contact Name

* PBM Primary Contact Email

Broker/Consultant

Other Broker/Consultant Name:

* Broker / Consultant Primary Contact Name

* Broker / Consultant Primary Contact Email

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