2023 Ambulance Membership Program

Personal Information

• * First Name:

• Middle Initial

• * Last Name:
• * Date of Birth
• Social Security #
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• Address 2:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:

• Fee

  Type	Fee
  One Person/Primary	$37.50
  One Person + Dependent/Spouse	$56.25
  Primary + 2 Dependents	$75.00
  Primary + 3 Dependents	$193.75
  Primary + 4 Dependent	$112.50
  Primary + 5 Dependent	$131.25

• 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 and Dependent Information

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

• Spouse/Dependent First, MI & Last Name
• Date of Birth:
• Relationship to Primary Member
• Social Security Number
• Dependent First, MI & Last Name
• Relationship to Primary Member
• Date of Birth:
• Social Security #

Insurance

• * Name of Primary Medical Insurance Company
• * Group ID/ Medical ID
• Address:
• * Phone #
• Name of Secondary Medical Insurance Company
• Group ID/ Medical ID
• Address:
• Phone #

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?

  • Yes
  • No