HomeMy WebLinkAboutC04-318 Eagle County Ambulance District(~,oH-3ig-az
EAGLE COUNTY AMBULANCE PERMIT
LICENSURE FOR: Julv 2004 TO: Julv 2005
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 2003 FORD III
#3 2002 FORD III
#4 2001 FORD III
#5 2000 FORD III
#6 1999 FORD III
MEDICAL ADVISOR: Diana Hearne, M.D.
The inspection of the above named ambulances was made on Aug ust 30, 2004 by Kristin
Diedrich R.N. Linda Maggiore, R.N. This ambulance service has met licensing
requirements for Eagle County as established in the resolution as approved by the Board
of Commissioners No ber, 1990.
INSPECTORS:
Kristin Di rich, R.N.
,'~-~fnJ
~~
Linda Maggiore, R.N.
Date:
EMERGENCY MEDICAL SERVICES
APPLICATION
J AMBU' LtANCE SERVICE LICENSE
Date of Application: ~ I ~./~"1
Name of Ambulance Services:
(owner or parent company) Eagle County Health Service District
Doing Business As: Eagle County Ambulance District
Address:P•0. Box 990 Edwards, Colorado 81632
Name And Address Of Each Stockholder Or Partner owning 10% Or More
Of The Outstanding Stock Of The Company Or Having More Than A 10%
Ownership Interest (if applicable):
N/A
Name, Address And Phone Number of Manager Or Individual Responsible for
The Operation Of The Services: Lyn Morgan, General Manager
P.O. Box 990 Edwards, Colorado 81632 (970)926-5270
What Area Of Your County Wiil Be Served By This Company? Please Attach A Map Indicating
The Service Area.
Eastern portion of Eagle County from mile marker 154 on I-70 to mile marker 190
Then north and south to Routt and Lake county lines.
List All Location (Central Station And Sub Stations) where ambulances
are to be located. Attach Zoning Authorization If Appropriate.
Edwards Builing (headquarters) 1055 Edwards Village Blvd. Edwards CO.
Vail Building 181 W. Meadow Drive Vail, CO.
How Many Ambulances Do You Operate? 6
If This Is An Initial Application (not a renewal application) Attach
A SEPARATE Permit Request For Each Ambulance.
Provide Name And Address Of Your Insurance Carrier:
See attached Certificate of Insurance
Name Of Agent: _
ATTACH A CERTIFICATE OF INSURANCE TO THIS APPLICATION.
I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS
APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO
WILLFUL MISREPRESENTATION OR FALSIFICATION.
DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE
INFORMATION CONSTTTUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL
PROSECUTION.
'I. ~ 2 3
Signature of Ap icant Date
{{~~ ~r~
SUBSCRIBED AND AFFIRMED BEFORE ME THIS ~3 DA1~t ~` I9 , IN THE COUNTY
OF ~--~ ,STATE OF CDO.
~~ 111'fl~~
~"lX~/~L~""_--
Signature of Notary
My Commission expires: ~ / ~/ /
(For Office Use Only)
Date Received: ~ / ~0 / O ~ /
Documents Checked: '~
Fee Paid or Excused:
Remarks:
,/2~f ~ ~ct,~.~ ~G1rt~
Receipt #:
Approval Recommended (Y/N): ~%'~'`'"
Date Ref rred to B.O.C.C. 7 / Z~ / ~/
/~
Licensing ent
~-
-~C
To
Grand
'unction
Flat Tops
Detl~ , W-Iderness Area
~ C~~e,{,
White River
National Forest
~`
,L`v
ti
`~
,~
~J
G°
W~cRD
To
Steae,~oat Springs
'~ McCoy
Bond
Burns ' • _ ~
-~-
Stat Bridge ¢ ~';•
i
- '~~~ White River
- '~~. National Forest
- ~,.
1
' -~-
t CAD
Wolcott
~o, ' ~ ~] .
6 ~-'
I.u~lc~ n~vc~,-^ GYpsum
tsero Eagle County
Regional Airport
EAGLE
COUNTY
~/ '
' ~ ' ~rouucernlp Cntf
Eagle Edwa ~. _ Avon ~ Yail
~o
\ ,-~77T1!('!1['(!(I (iulrC(1f~1\~ ~ ~a Ie~Yall (`'
a
''~ C.iuililh•r'rr
.~
White River
National Forest
~,.
--,
. ~;«,~
Primary coverage in the Roaring Fork:
Basalt Fire and Ambulance District
• E1lebel
•/~~ Basalt rl j~tll`~Cllt nu~cq• RuedfReserrrotr
..//~~ as
N
V T.. JI.....,..
S~~tt~mr Lrtke
'~<•rrd Ski :IrT•cL] 9
~ -}tu (lr,lf•G7rrn
' ~5T !•k Calf C.iurr~~ ~ _
\ 1 irilSkt:Lrn
K<•nr•<•rCrit~C
5ki.9n~r ~1«~I<~-I7ri! ~ Minturn
r1•J ~ ro~'Cruu.r
`
.
n ,a
^ ~ s}
.
~.. a n
;,
-
Gilman
~~ Red Cliff
,,
ti
~'
~C
1
V ~
~u 2~
uC
~`
-
~°~
Jlonresln c ~ -
7
~1 To Dem
r~
r-~
,
- ~• ~~
};`. ~ _ _u LSSUE DATE (MM/DD/YY)
~ ~ ~tV' r rwq~ ~ ,',.
` ~ ~ ~
~
`
.~ ;: ~.~y ,.- .t.-~ at =
.,,
~ 1
7/3 0/2004
PRODUCfiR TIUS CHRTIFICATB IS ISSUED AS A MATTER OF INFORMATTON ONLY AND CONFERS NO
RIGHTS UPON THB CBRTIFICATH HOLDBR THIS CBRTD~ICAYE DOES NOT AMEND EXTEND
Earl McFarland Insurance Agency Inc. OR ALTER THE COVERAGE AFFORD BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
dba VFIS of Colorado
128 6th Unit C cotKrANY
Windsor, Colorado LETTER A AAIC
80550 coMPANY
LETTER B
COMPANY
Eagle County Health Services District
LETTER C
COMPANY
PO Box 990 TTER D
LE
coMPANY
Edwards, Colorado 81632
E
LETTER
~~ r~.,.~ ~t~. -~. y
THIS LS TO CERTIFY THAT TH6 POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE DvSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OA OTBER D00011>ENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY TEATAIN, THE INSURANCE AFFORDED BY THE POLICIES DE3CRmED HEREIN IS SUBJECT TO ALL THE TEAMS
EXCLUSIONS AND CONDITIONS OF SUCH POWCIES. LIIIDTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO ME OF INSURANCE POLICY NUMBER POLICY EFF. POLICY EXP. L~TIs
LTR DATE (hIlN/DD/YY) DATE (Flhl/DD/YY)
A GENERAL LIABILITY VFIS-CL-020273-2 1/1/04 1/1/05 GENERAL AGGREGATE $ 3,000,000
FTY
NERAL LL-BH
G
® PROD-COMP/OPAGG. $ 3,000,OOU
.
COMM.
E
DE ®OCCUR PERS. ~ ADV. INJDRY $1,000,000
CLAMS MA
6 CONTRACT'S PROT
' EACH OCCURRENCE $ 1,000,000
.
OWNER
S
FDUE DAMAGE (Oee Eke)
$ 1,000,000
MED. EXTENSfi (One Per) $ 5,000
AUTOMOBH.E LL-BH1TY VFIS-CL_0020273-2 1/1/04 1/1/05 coMBwED snvcLE $1,000,000
LIMTT
®ANY AUTO
ALL OWNED AUTOS BODII,Y INJURY
(Per Ptrwn) $
SCHEDULED AUTOS
NIRED AUTOS BODII,Y WJURY
(Per Accident) $
NON-OWNED AUTOS
GARAGE LIABII.ITY PROPERTY DAMAGE $
n
A E
XC~3 ~~ VFIS-CL-0020273-2 1/1/04 1!1/OS ®EACH OCCURRENCE $1,000,000
Management
Liability
UMBRELLA FORM ® AGGREGATE $ 3,000,000
3 ~ ~ ~ ~ ~ 4°~ •
OTHER THAN UMBRELLA FORM STATUTORY LBrH7'S .
v r „ 4'~f ~. r,
WORKERS' COMTENSATION EACH ACCIDENT $
AND DISEASE POLICY LUHIT $
EMPLOYER'S LiABH.ITY DLSEASE-EACH EMP. $
OTHER
DESCRICf10N OF OPERATIONS!LOCATIONS/VEHICLESBTECIAL 1TEM5
Purpose is to show proof of coverage for licensing purposes.
SHOULD ANY OF THE ABOVE DESCRBED POLICIES sE CANCELED BEFORE TILE EXTIRATION
Eagle County Health Services District DATE THEREOF, THE ISSUING COMPANY WIId. ENDEAVOR TO MAIL 1QDAY5 WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMID TO THE LEI+T, BUT FAII,U RE TO MAII. SUCH
NOTICE SHALL IMPOSE NO OBLIGATTON OR LIABILITY OF ANY KII'ID UPON THE COMPANY, ITS.
AGENTS OR REPRESENTATIVES
~~~ AUTHORIZED RElRESENTATIVE
s ~.t 'r, .
,~.
