Southeastern Wisconsin
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SOUTHEASTERN WISCONSIN COMMON GROUND www.commongroundwi.org
WISCONSIN HEALTH CARE COOPERATIVE INTENTION FORM
Understanding these key elements of the proposed Wisconsin Healthcare Cooperative:
1) It is open for membership to small businesses, self-employed individuals and non-profit organizations throughout Wisconsin. 2) A member who joins agrees to stay for a three year period. 3) A Board of Directors runs the Cooperative and is elected by the members. 4) Signing this intention does not legally obligate you to join WHC.
I/We would become part of the Wisconsin Healthcare Cooperative if/when it is formed:
Business/Organization:
Contact Person:
Address:
City:
State:
Zip:
Phone:
Email:
Estimated # of Individuals to be covered:
Estimated Annual Premium:
Return to: Common Ground Healthcare Committee 1034 E. Ogden Avenue Milwaukee, WI 53202 FAX: 414-272-0199 Bob Connolly: Phone – 414-272-0101 Email – [email protected]