SUNSTAR FirstCare Ambulance Membership Application and Agreement - 2020Ambulance Membership Agreement • November 26th, 2019
Member 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.
