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HomeMy WebLinkAboutC03-238 Eagle County Ambulance District EAGLE COUNTY AMBULANCE PERMIT LICENSURE FOR: July 2003 TO: July 2004 AMBULANCE SERVICE: Eagle County Ambulance District P.O. Box 990 Edwards. CO 81632 Phone 926-5270 Fax 328-1132 VEHICLE YEAR MAKE TYPE # 1 2003 FORD III #2 2002 FORD III #3 2001 FORD III #4 2000 FORD III #5 1999 FORD III #6 1998 FORD III MEDICAL ADVISOR: Diana Hearne. M.D. The inspection of the above named ambulances was made on July 24.2003 by Kelly Liekis, RN. Linda Maggiore, RN. This ambulance service has met licensing .. requirements for Eagle County as established in the resolution as approved by the Board of Commissioners N/JoJvfember,1990. / INSPECTORS: ~/l1/ ~ hC_J~1~.!/~l/ . ~-~ . elly Liekis, RN. Date: ~ ~~ ~~~~~`~=~ ~. ,, . ~: ' GENCY MEDICAL CES' APPLICATION AMBULANCE SERVICE LICENSE ~~ ~ ~ ~ ~~ - Date o~,A,pplscatzon: Name of Ambulance Services: (owner ox parent comps Doing Busipess As: I~ A~r~c~ ~ 0 6 ~k- ~ ~ G ou r ' ~I 71+x/, wl.dc~ .-~c~.~,Ja,~ cS s C~ a:~-.. ~J I S^~ s~ ~4-- g[e~z Name Aad. Address Of Each Stockholder Or Partner owning 10% Or More O£':ihe Outstanding Stock Oaf Tne Coxnps~ny Or Having More Ti'Eaau, A 10% Ownership Interest (if appIic~.ble): . Name, Address And Phone Number of Maaagex Or Individual Respons~tubke for The Operation Of The Services: L s~Y1 O ~, ® ~ ~ ~- qq a ~~~..,~ s Ca 8l ~ a z q~ n -- as c~ -5 ~--s~ 4-~ d - 9 ^ ~3s' ~Vbat Area Of Your County Will Be Served By This Comps3ny2 Please Attach A-• Map Iadi , The Se.-vice A;;~z. .~zaskm~ ~c~t~- Cour..~,, list AlI ~,ocatiom (Cep 3tatiosl And Sub statio;',s) whew ambulances are to be Ios;,ated. Attach Zoning Authorization If Appropriate. I®~~' Cc~c.~arc~s U~lla-,z~~ E~I~~ , ar~s Co How Many Ambulances Do You Operate? If This Is Aa Initial Applicaxion (mvt a renewal application) Attach b/Z 'd £~l6'~N SHH AlNH09 31943 wda£~ << £ooa 'S~'~~v .r ~ y~;PpR,A7E Permit est For Each Ambulaflce. provide Name And Addressour Insurance Carrier: Vt~~ ©~' c~C~r~ ~"r 1 l q of o Cs~ r4~k S~- , gE e~ `k a ° _ ~ . ~ oa TliunoOFAgen~ ~ad~ 1~~~r~e~~~ lUS . ~qau. T .;~ A•~'/1CH A CER'I~CATE OF INSURANCE TO'1'HIS APP CATION. ! 1IC1tEBX CER~'IFX TEAT Tif~E INFORMA'CION PROVIDED IN T>IaS APr~.IGA~ON IS TRUE TO TIDE BEST OF 1VlY KNOVYI,EDGE AMID BELIEF AND CONTAINS NO WILLFUL N~ISREPRESENTAT~ON OR FAIaSIF;iCATION. DETr:RMIDATION TART AN AIVxBULANCE 51;RVXCRS LICENSE SAS BEk~i ISSUED BASED ON F,A,T~SE INFt)i~MA'I'ION CONSTIT[JTES OROUNBS FOIL LIC.LNSL REdOCATi®N ANA POSSIBLE CRT,NIIN,AL pRI)~EC[T'I'ION. ~~~ sr ~€A~ t D~ 5tli3SCRIB€D ,~N'L' R~'FIP.tJd'EL' 3~'O~F ~ .TITS t ~.~2AX '~ , I . ~'I=~ CQiJ~ITY sTAT~ o~ coLbRADO. OF ~c~~~._ Slguanu~e o#'Nntary My Commission eXpires:~ ~ ,~/ (Far O,ffitce Use Owly) . pa~c ltcceived: / / / Fee dead ar Excused: Doarmems Checked: Receipt ~: Ren„-rks: Approval Recommended (Y/N): pate Refeaed to B.O.C.C.~ _/ _J Licensing A.gemt ' 7 £/E 'd 9~16'~N SHH AlNNO~ 3193 Wdl~~ll £OOl '~l'~~~ CERTIFICATE INSURANCE ` ~ LSSUE DATE (MM/DD/YY) ,,1 5,2003 PRODUCER THIS CERTR7ICATH IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THLS CBRTIFICATE DOPE NOT AMEND. EXTEND Earl McFarland Insurance Agency, Inc. OR ALTER THE COVERAGE AFFORD BY THE POLICIES BELOW. VFT5 of Colorado 11990 Grant Street, Suite 420 COMPANIES AFFORDING COVERAGE Northglenn, Colorado 80233 coMPANY LETTER A AAIC coMPANY LETTER B INSURED COMPANY Eagle County Health Services District LETTER C coMPANY PO Bo% 990 LETTER D coMPANY Edwards, Colorado 81632 LETTER E COVERA~Es THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LLSTID BELOW HAVE BEEN ISSUID TO THE INSURED NAMID ABOVE FOR THE POLICY PERIOD IlVDICATID. NOTWITHSTANDING ANY REQUHtEhIIIVT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRDJID HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LDiIITS SHOWN MAY HAVE BEEN RIDUCED BY PAID rr.ernrc, CO TYPE OF INSURANCE POLICY NUMBER POLICY EFF. POLICY EXP. LDrII1°S LTR DATE (hEN/DD/YY) DATE (MP7/DD/YY) A GENERALLIABH.ITY VFIS-CL-0020273-1 1/1/03 1/1/04 G~RSr.AGGREGATE $ 3,000,000 ® COMM. GENERAL LIABII.IT'Y PROD -COMP/OP AGG. $ 3000,000 ^ CLAIMS MADE ®OCCUR PERS & ADV. INJURY $ 1,000,000 ^ ~~ ~~ 000 $ 1 000 OWNER'S & CONTRACTS PROT. , , ^ FneE DAMAGE ~o~ Fae~ $1,000,000 MED. EXPENSE (One Per> $ 5,000 A AUTOMOBH.E LlASUSrY VFIS-CL-0020273-1 1/1/03 1/1/04 CO~"~,Is1ED ~"~ $1,000,000 ®ANY AUTO ^ BODII.Y INJURY ALL OWNID AUTOS (Per Person) ^ SCHEDULID AUTOS ^ HIRED AUTOS BODII.Y INJURY $ OWNID AUTOS ^ NON (Per Acddent) - ^ GARAGE LIABII.ITY PROPERTY DAMAGE $ EXCESS LIABIIITY ^ EACH OCCURRENCE $ ^ UMBRELLA FORM ^ AGGREGATE $ ^ OTHER THAN UMBRELLA FORM ti STATUTORY LIMITS ti WORKERS' COMPENSATION EACH ACCIDENT $ AND DISEASE POLICY LEVHT $ EMPLOYER'S LIABIIITY DISEASE-EACH EMP. $ OTHER DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLESISPECIAL TI'EMS Purpose is to specifically show coverages on for licensing __ purposes. See attached list. CERTTPT~~'1'Elit)~DER CANCELT~ATION ~. Ea le Count SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELED BEFORE THE_ExPIRATION g y DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAII. 10 DAYS WRITTEN P O BO% 8SO NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAH. SUCH . . NOTICE SHALL EVIPOSE NO OBLIGATION OR LIABH.IIY OF ANY KIND UPO N THE COMPANY. ITS. Colorado 81632 Ea le AGENTS OR REPRESENTATIVES g , AUTHORIZED RESENTATIVE mac:©RD ~~-sf,~goT .~ ` ~ .. , VEffiCLES COVERED UNDER EAGLE COUNTY HEALTH SERVICES DISTRICT AUTO POLICY #VFIS-CL-0020273-1 Veh. # Year, Make Vin. # 1. 1998 Ford Ambulance 1FDWE30FOWHA45463 2. 1999 Ford Ambulance 1FDWE30F1XHA14076 3. 2001Ford Ambulance 1FDWE35F61HA57750 4. 2000 Ford Ambulance 1FDWE35F7YHA29756 6 1998 Ford 1St Responder 1FMZU34EOWZA99891 7. 2001 Ford 1St Responder 1FN1PU16LX1LA86925 8. 2001 Ford 1St Responder 1FMPU16L81LA86924 10. 2002 Ford Ambulance 1FDWE35F82HA21091 11. 2003 Ford Ambulance 1FDWE3SF53HA60870 .P 8T '1 1 I I ••4 y( i .4 I I - ~} ti V ~~ , r- ,I J ~ ~ ' ~, _ ' e rI r. _ - j. ~~`' Vii, ~ ~`~~ ~~„ IJ I .`t. ~ i .f ,, `y. ` _ ~ .1 I 3 I 'i~ ~ _ 1 '( s..i • ~ 1 ' ,J. • r ~ : ~ of .1 . I 1 _.. 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