I hereby apply for an Essex Rescue Subscription covering all people living within my house listed on this agreement. I understand that the $50 per household is not prorated and provides unlimited pre-hospital emergency care, when medically necessary, to me and my listed household members within the primary service area covered by Essex Rescue. The subscription does not apply if another ambulance service transports you or members of your household within our service territory.
The subscription will begin when payment is received and end on the last day of the calendar year. If subscription begins in October, November, or December, it will apply throughout the full following year.
This subscription is terminated if the subscriber moves outside Essex Rescue's primary service area. I understand that if any member of my household uses services of Essex Rescue, a bill will be sent to my insurance company and that I will not be responsible for a co-payment or deductible. Any payment I receive directly from my insurance company must be forwarded to Essex Rescue. This subscription is non-refundable and non-transferable. I authorize payment of medical benefits to Essex Rescue.
Any amount paid in addition to the $50 subscription fee is a donation which is greatly appreciated by Essex Rescue. Gifts and donations to Essex Rescue, a 501 (c)(3) non-profit organization, are tax deductible within the limits of federal and state laws. Essex Rescue does not provide goods or services as whole or partial consideration for any donations or gifts. Please keep a copy of this form for your tax records along with your canceled check or bank statement.
If you have questions, please call or email Sean McCann
, 802-878-4859 ext 4.