West Covina Fire Department Ambulance Program
This file contains the application form for the West Covina Fire Department's Ambulance Subscription Program, which is available to local businesses. It details the membership benefits, eligibility, payment information, and the terms of agreement for subscribers. The program provides coverage for medically necessary ground ambulance transportation for employees.
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How do I fill this out?
To fill out this application, please ensure you have all the required information at hand. Start by providing your business details and contact information. Finally, carefully review the terms of the agreement before submitting the application.
How to fill out the West Covina Fire Department Ambulance Program?
1
Gather your business and employee information.
2
Complete the membership application form.
3
Indicate the number of employees for coverage.
4
Sign and date the application form.
5
Submit the form along with payment as directed.
Who needs the West Covina Fire Department Ambulance Program?
1
Local business owners who wish to provide ambulance coverage for their employees.
2
Employees of businesses in West Covina seeking transportation benefits.
3
Human resource managers looking to manage employee benefits.
4
Residents of West Covina involved in business operations.
5
Community organizations partnering with local businesses for employee welfare.
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What are the instructions for submitting this form?
To submit this form, please mail the completed application along with payment to the following address: City of West Covina, PO Box 269110, Sacramento, CA 95826-9110. You may also call Wittman Enterprises at (800) 906-6552, press 4 then 3, to enroll over the phone. Ensure to double-check all entries for accuracy before submission.
What are the important dates for this form in 2024 and 2025?
All applications for the Ambulance Subscription Program should be submitted by the end of each calendar year to ensure coverage for the upcoming year. It is advisable to renew memberships annually before the policy expiration date. Keep an eye on specific deadlines communicated by the City of West Covina.
What is the purpose of this form?
The purpose of this form is to facilitate the enrollment of local businesses and their employees in the Ambulance Subscription Program managed by the West Covina Fire Department. It outlines the necessary details needed to ensure that employees have access to essential ambulance services when required. By completing this form, businesses can secure the transportation needs of their employees in medical emergencies.
Tell me about this form and its components and fields line-by-line.
- 1. Business Name: Name of the local business applying for membership.
- 2. Business Address: Physical address of the local business.
- 3. Contact Person: Name of the person to contact regarding the application.
- 4. Phone Number: Contact number for the business or representative.
- 5. Email Address: Email for correspondence related to the program.
- 6. Employee Details: Information specific to each employee seeking coverage.
- 7. Payment Information: Details regarding payment method for the membership fee.
What happens if I fail to submit this form?
If you fail to submit the application form, your business and employees will not be enrolled in the Ambulance Subscription Program. Consequently, they will miss out on the ambulance coverage benefits when emergencies arise. It’s essential to complete and submit the form on time to avoid such concerns.
- Lack of Coverage: Without submission, employees cannot access the ambulance services.
- Financial Responsibility: Employees may face out-of-pocket expenses for ambulance services.
- Limited Access to Emergency Services: Non-members may experience delays in receiving necessary medical transportation.
How do I know when to use this form?
- 1. Annual Enrollment: Use the form during the annual enrollment period for new and renewing members.
- 2. Employee Changes: Submit when there are changes in employee numbers needing coverage.
- 3. Coverage Updates: When modifying existing coverage plans or details.
Frequently Asked Questions
How do I access the ambulance application form?
You can download the application form from the official West Covina website or use PrintFriendly to access and edit it.
What are the qualifications for membership?
Membership is available to local businesses and their employees in West Covina.
How do I submit the completed application?
You can submit the completed application along with payment via mail to the City of West Covina's designated address.
Is there a fee for signing up?
Yes, the annual membership fee is $69.00 for every 10 employees.
What does the membership cover?
The membership covers medically necessary ground ambulance transportation for employees.
Can I edit the form before submitting?
Yes, you can easily edit the form using PrintFriendly before submitting it.
How is payment made?
Payment can be made using a check payable to the City of West Covina.
Is there an option for credit card payment?
Currently, credit cards are not accepted, but this may be available in the future.
What happens if I don't submit the form?
If you fail to submit the form, you will not have access to the benefits of the Ambulance Subscription Program.
Who can I contact for more information?
For inquiries, please call (800) 906-6552, press 4, then 3 to bypass the menu.
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