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About
- About
- Advisory Council
Our Work
- What We Do
- Who We Serve
Member Directory
Events
Resources
Join

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Complete the membership application below to join. If you have questions, please reach out to info@employercoalitionla.org.

"*" indicates required fields

Which type of membership are you applying for?*

Employer

General

Affiliate

Applicant Company Name*

Type of Industry*

Primary Contact Info

Name*

First Last

Title*

Address*

Phone*

Email*

Secondary Contact

Name*

First Last

Title*

Address*

Phone*

Email*

Which Of The Following Categories Best Describes Your Organization’s Services?*

Brokerage

Pharmaceutical/biomedical services & products

Health & wellness program

Quality measurement & improvement

Benefits consulting

Pharmacy benefits management

Disease management/care management

Health insurance

Other

Health Plan Funding Model*

Self-funded

Fully-insured

Medical Benefits

Vendor(s)

Pharmacy/PBM Services

Vendor(s)

Pharmacy/PBM Services*

Pharmacy benefits not provided

Pharmacy benefits offered through the same insurer/TPA as medical benefits

Do You Offer Retiree Medical Benefits?*

Yes

No

Retirees <65 – Type and name of health plan(s)*

Retirees >65 – Type and name of health plan(s)

Vision benefits vendor(s)

Employee Assistance vendor(s)

Dental Benefits vendor(s)

Benefits consulting organization(s)

Employee well-being vendor(s)

OPTIONAL: Describe your organization’s value-based care and payment arrangements and results to the extent you are able to share this information. Use additional page(s) if necessary.

Total number of employees*

In Louisiana

In The U.S.

Number of benefit-eligible employees*

In Louisiana

In The U.S.

Total number of covered lives (employees & family members)*

In Louisiana

In The U.S.

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Consent

Consent*

By signing below, I am indicating that I am authorized to commit my organization to joining the Employer Coalition of
Louisiana. I understand that my organization will be invoiced based on the established fee schedule. My organization
may choose to terminate its membership at any time, but will not be entitled to a refund of dues paid.

I agree

Full Name*

Title*

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Baton Rouge, Louisiana 70809

Fax (225) 344-9847

info@employercoalitionla.org

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