Where

Arvada Fire

7903 Allison Way
Arvada, CO 80005

Event Address Map
Driving Directions

Contact

Arvada Fire
Arvada Fire
303-424-3012
amanda.pollard@arvadafireco.gov

2024 Ambulance Membership Program

2024 Ambulance Membership Program Coverage starts from October 2023-December 2024

* Required information

Personal Information

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

  • Fee

    Type Fee
    $50.00
    $75.00
    $100.00
    $125.00
    $150.00
    $175.00
    $200.00

Spouse and Dependent Information

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Insurance

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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 companies will be billed for payment, and that any co-payment or deductible required under my insurance policies not paid by my insurance will be paid by the Arvada Fire Ambulance Membership Program, subject to limitations stated in, and in accordance with the Terms of Agreement in full satisfaction of Arvada Fire Protection District's emergency medical/ambulance charges.

  • To my insurance carriers or other provider of medical benefits: *I authorize a copy of this Ambulance Membership Enrollment form to be used in lieu of the original copy on file at the Arvada Fire Protection Districtís Headquarters. *I authorize payment 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/ambulance services pursuant to my policies to be sent directly to the Arvada Fire Protection District.

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    Do you agree with the above terms and conditions?

$9,999.99

Payment

Payment Method

  • Please make check payable to:
    Arvada Fire Protection District
    7903 Allison Way
    Arvada, CO 80005

Payment Summary


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