Amelia Emergency Squad's EMS Care Subscription

EMS Care Subscription

Subscription covers July 1, 2024 through June 30, 2025. Open enrollment is through July 31, anytime thereafter subscription will not backdate and will only provide eligible subscriptions with coverage from date of purchase through June 30, 2025.
Subscription Options*
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EMS Care - Individual/ Individual and SpouseEMS Care for individual and/or individual plus spouse. Please note that if you are not married, you must file and pay for two separate EMS Care subscriptions.
$75.00

EMS Care - FamilyEMS Care for your whole family! Please note that this applies only to your spouse and dependents. If you have an adult child, in-law, parent, etc. residing with you, they will need a separate EMS Care subscription.
$100.00

Total

$0.00

Subscriber Name

First Name and Middle InitialLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email Address
Phone Number
Date of Birth

MonthDayYear
Last 4 of Social Security Numberblanks
Spouse Name (leave blank if none)

First Name and Middle InitialLast Name
Date of Birth

MonthDayYear
Relationship to subscriber
Last 4 of Social Security Numberblanks

Dependent #1 Name

First Name and Middle InitialLast Name
Date of Birth

MonthDayYear
Relationship to Subscriber
Last 4 of Social Security Number blanks
Dependent #2 Name

First Name and Middle InitialLast Name
Date of Birth

MonthDayYear
Relationship to Subscriber
Last 4 of Social Security Number blanks
Dependent #3 Name

First Name and Middle InitialLast Name
Date of Birth

MonthDayYear
Relationship to Subscriber
Last 4 of Social Security Number blanks
Special Instructions/ Any additional dependents

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