<p> SOUTHEASTERN WISCONSIN COMMON GROUND www.commongroundwi.org</p><p>WISCONSIN HEALTH CARE COOPERATIVE INTENTION FORM</p><p>Understanding these key elements of the proposed Wisconsin Healthcare Cooperative:</p><p>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.</p><p>I/We would become part of the Wisconsin Healthcare Cooperative if/when it is formed:</p><p>Business/Organization: </p><p>Contact Person: </p><p>Address: </p><p>City: </p><p>State: </p><p>Zip: </p><p>Phone: </p><p>Email: </p><p>Estimated # of Individuals to be covered: </p><p>Estimated Annual Premium: </p><p>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] </p>