LFPD Ambulance Subscription Enrollment Form

Louisville Fire Protection District

Ambulance Membership Program - 2024 Enrollment Form
Name*

Last NameFirst Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please check the type of membership requested:

$25 Individual - Covers only the individual signing this form.$45 Couple - Covers the individual signing this form and spouse living at your residence.$65 Family - Covers the individual signing this form and all family members, including unmarried children under age 25 and other dependents listed on your tax return and regularly living at your residence.$35 Senior Couple - Covers the individual signing this form, who must be age 55 or older, and spouse living at your residence.$55 Senior Family - Covers the individual signing this enrollment form, who must be age 55 or older, and all family members, including unmarried children under age 25 and other dependents listed on your tax return and regularly living at your residence.

Please list all family members including children under age 25 and other dependents listed on your tax return and regularly living with you.*
Primary Medical Insurance:*
Policy or ID# :*
Address & phone :*
Secondary Medical Insurance :
Policy or ID# :
Address & phone :
Auto Insurance :
Auto Insurance Policy # :
Address & phone :

To my insurance carrier(s) or other provider of medical benefits:
- I authorize a copy of this enrollment form and agreement to be used in lieu of the original on file at the Louisville Fire Protection District's office.
- I authorize payment of benefits be made directly to the Louisville Fire Protection District for emergency medical/ambulance transport services for eligible family members or myself.
- I authorize and direct reimbursement for emergency medical/ambulance services pursuant to my policy(ies) to be sent directly to the Louisville Fire Protection District.
Signature*

Clear
Date Signed*
Should be Empty:

Louisville Fire Protection District