When

Tuesday, February 4, 2020 at 1:00 PM MST
-to-
Friday, January 1, 2021 at 1:00 AM MST

Add to Calendar

Where

Arvada Fire

Contact

Arvada Fire Protection District
Arvada Fire Protection District
303-424-3012
gail.benker@arvadafire.com

Ambulance Membership Program Enrollment Form

* Required information

Personal Information

  • *
  • *
  • *
  • *
  • Fee

    Type Fee
    $12.50
    $17.50
    $25.00

  • Maximum Plan Benefit/Year $500 for Primary Member $1,000 for Primary Member + Spouse or dependent $1,500 for Primary Member + 2 family members

Spouse & Dependent Information

  • If you have more than a primary member + two residents please contact our Headquarters for additional enrollment options.

Insurance Information

Signature

  • I represent that the forgoing information is true and accurate. I have read and agree with the Terms of Agreement- Arvada Fire Protection District Ambulance Membership Program. I further understand and agree that my insurance company(ies) will be billed for payment, and that any co-payment or deductible required under my insurance policy(ies) not paid by my insurance company(ies) will be paid by the Arvada Fire Protection District Ambulance Membership Program, subject to the limitations stated in, and in accordance with, the Terms of Agreement in full satisfaction of Arvada Fire Protection District's emergency medical/ambulance transport charges.

  • To my insurance carrier(s) or other provider of medical benefits: *I authorize a copy of this Ambulance Membership Program Enrollment Form to be used in lieu of the original on file at the Arvada Fire Protection District's Headquarters. *I authorize payments of benefits for emergency medical/ambulance transport services for myself or eligible family members directly to the Arvada Fire Protection District. *I authorize and direct reimbursement for emergency medical/ambulance services pursuant to my policy(ies) to be sent directly to the Arvada Fire Protection District Submission of this application with payment constitutes acceptance of the Arvada Fire Protection District terms of agreement located on the Arvada Fire website.

  • *

    Do you agree with the above terms and conditions?

$9,999.99

Payment

Payment Method

  • Please make check payable to:
    Arvada Fire
    ATTN: AMP
    7903 Allison Way
    Arvada, CO 80005

Payment Summary


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