Essex Rescue - Essex Junction, Vermont

2013 Responses
Jan	147
Feb	120
Mar	145
Apr	123
May	0
Jun	0
Jul	0
Aug	0
Sep	0
Oct	0
Nov	0
Dec	0
Total	535

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Essex Rescue Subscription Agreement
(January 1, 2013 to December 31, 2013)

The subscription plan offered by Essex Rescue is a unique plan designed to help you and the members of your immediate household control your health care costs and at the same time, support the efforts of our volunteers. Your health insurance will be billed for the use of our ambulance for medically necessary services. If you are a participant in our subscriber plan, the co-pay or deductible amount unpaid by your health insurance will be waived. Your insurance company will be billed for our services and we will accept the amount paid by your insurance company as payment in full. Contact Colleen Nesto at (802) 878-4859 x4 for more information.

Subscription Letter

Subscription Brochure

Subscriber Information

Name:

Date of Birth:

Address:

City, State, Zip:

Phone:

E-mail:

Please list name and age of all others living in your household

Name

Date of Birth (mm/dd/yyyy)

Subscription Plan

Subscription Amount

$300+ Platinum Subscriber
$200 Gold Subscriber
$100 Silver Subscriber
$50 Subscriber (minimum)

I hereby apply for an Essex Rescue Subscription covering all people living within my house listed on this agreement. I understand that the minimum amount of $50 per household is not prorated and provides unlimited prehospital emergency service, when medically necessary, to me and my listed household members by Essex Rescue and within the boundaries of Essex Junction, Essex Town, Jericho (excluding areas south Barber Farm Rd.), Underhill, and Westford.

The subscription will begin on January 1, 2013 and will end December 31, 2013. This subscription is terminated if the subscriber moves from the above listed towns. I understand that if any member of my household uses the services of Essex Rescue, a bill will be sent to my Insurance Company and that I will not be responsible for a copayment or deductible. Any payment I receive directly from my insurance company must be forwarded to Essex Rescue. This subscription is nonrefundable and nontransferable. I authorize payment of medical benefits to Essex Rescue.

I have read and agree to terms and conditions stated above

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www.FirehouseSolutions.com	Essex Rescue, Inc. 1 Educational Drive Essex Jct., VT 05452	Emergency Dial 911 Non-Emergency: 802-878-4859 Station Fax: 802-878-1246