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Medi-Share Employer Program Registration Form

Medi-Share Employer Program Registration Form

* Indicates Required Field

Organization Information

* Name of Organization:

* Phone:

Fax:

* Billing Address:

* City:

* State:

* Zip Code:

* EIN # (Employer Identification Number):

I am representing a church I am representing an organization other than a church

I affirm that my organization is in agreement with the Christian Care Ministry Statement of Faith and hereby understand that enrollment in this program provides Christian Care Ministry the right to acknowledge my organization's affiliation.

Employer Program Administrator Information

Please enter the information for the Administrator below. This person will be designated the primary contact for the Medi-Share Employer Program.

* First Name:

* Last Name:

* Email:

* Phone:

Phone Extension:

Cell Phone:

Sales Rep/New Member Representative (Agent):

Please include the Administrator on the Employer Program membership.

Employee Head of Households

Please enter the details below for each employee head of household who will be joining the Employer Program membership. Include the administrator if they plan to join.

Manual Entry CSV Entry

Please use this CSV template to enter the information for each head of household.

* CSV File:

Employer Program Administrator Signature

* As the authorized representative of the organization listed above, I hereby acknowledge that the organization listed will be responsible for making the monthly share payments for the above listed employee households.

Medi-Share Employer Program Registration Form

Organization Information

Employer Program Administrator Information

Employee Head of Households

Employee Household 1

Employer Program Administrator Signature