Volunteer EMS Insurance Program Interest

Volunteer EMS Insurance Program Interest

This information will help us connect you to your local EMS agency if you are a new volunteer, or begin the insurance enrollment process if you are a current volunteer. This is not the insurance application form. Please contact ems@utahcounties.org for the application form.
Full Name*

First NameLast Name
County*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Are you currently licensed under Section 53-2d-402 of the Utah Code as an emergency medical technician, advanced emergency medical technician, or a paramedic?*

Emergency Medical TechnicianAdvanced Emergency Medical TechnicianParamedicNot Licensed
How did you hear about the program?*
Please Specify If Other
Are you a current EMS Volunteer?*

YesNo
If you are a current EMS Volunteer, which agency are you with?
Should be Empty: