SUNSTAR FirstCare Ambulance Membership Application and Agreement - 2020November 26th, 2019
FiledNovember 26th, 2019Member InformationPlease read the FirstCare Membership Agreement prior to signing.The application must be signed by all members 18 years of age and over. Primary Member #1 Full Name: Social Security #: Birth Date: Primary Member #1 Address: Email Address: Member #1 Signature (Required): Date Signed: Phone#: Insurance Information Primary Insurance Name: ID/Contract#: Group#: Secondary Insurance Name: ID/Contract#: Group#: Additional Family Members Family Member #2 Name: Social Security #: Birth Date: Primary Insurance Name: ID/Contract#: Group#: Member #2 Signature (Required): Date Signed: Phone#: Family Member #3 Name: Social Security #: Birth Date: Primary Insurance Name: ID/Contract#: Group#: Member #3 Signature (Required): Date Signed: Phone#: Family Member #4 Name: Social Security #: Birth Date: Primary Insurance Name: ID/Contract#: Group#: Member #4 Signature (Required): Date Signed: Phone#: Payment InformationFOR YOUR SECURITY, CREDIT CARD PAYMENTS ARE NO LONGER ACCEPTED BY MAIL.
ContractNovember 7th, 2019
FiledNovember 7th, 2019Member InformationPlease read the FirstCare Membership Agreement prior to signing The application must be signed by all members 18 years of age and over Primary Member #1 Full Name and Address: Social Security #: Birth Date: Email Address: Member #1 Signature: Date Signed: Phone#: Insurance Information Primary Insurance Name: ID/Contract#: Group#: Secondary Insurance Name: ID/Contract#: Group#: Additional Family Members Family Member #2 Name: Social Security #: Birth Date: Primary Insurance Name: ID/Contract#: Group#: Member #2 Signature: Date Signed: Phone#: Family Member #3 Name: Social Security #: Birth Date: Primary Insurance Name: ID/Contract#: Group#: Member #3 Signature: Date Signed: Phone#: Family Member #4 Name: Social Security #: Birth Date: Primary Insurance Name: ID/Contract#: Group#: Member #4 Signature: Date Signed: Phone#: Payment InformationFOR YOUR SECURITY, CREDIT CARD PAYMENTS ARE NO LONGER ACCEPTED BY MAIL.If you would like to pay by credit card please submit a comp