All Trust Cooperative Membership Application – All Trusts Cooperative (ATC)

All Trusts Cooperative (ATC) is open to all self-funded health plans and the service providers and plan professionals working with these plans. A representative from ATC will follow up with detailed information on the participation levels.

Legal Name of the Fund *

Fund Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

International Union Affiliation *

Local or District Counil *

State(s) Represented *

Fund Size (as reported on the From 5500) *

Please Provide the Following Information for the Primary Contact:

District Union the

Primary Contact Name *

Primary Contact Job Title *

Primary Contact Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Contact Relationship to Fund *

Primary Contact Company or Union Affiliation *

Additional comment or message:

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