FOR QUARTERLY NEWS
PLEASE READ CAREFULLY AND CHECK THE BOX ON THIS FORM THAT YOU UNDERSTAND AND AGREE TO THE TERMS PROVIDED BELOW.
By completing this online form you are requesting to be enrolled in the Senior Membership plan for energy ambulance service.
Fill in the requested information as it applies to you.
There is a $50.00 non-refundable and non-transferable membership cost per year.
Membership runs from January 1st to December 31st. All payments must be submitted prior to February 28th in order to cover the participant for the remainder of the year.
Upon submission of this form, you hereby apply for a membership program for yourself and all other eligible members of my household. (spouse)
Membership fee provides Medically Necessary Emergency ambulance service(s) within the Lawson Fire District response area with no out-of-pocket expense to you.
You understand that non-emergency (routine) transports are not covered under this plan and will be billed accordingly.
You understand and confirm that this membership permits Lawson Fire & Rescue to collect directly from your insurance and any third-party agency whenever benefits or payments may be available.
I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the party who accepts assignments.
For questions please call the Department District Clerk at 816-580-3903