HomeMy WebLinkAboutC05-235 Eagle County Health Service District
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EAGLE COUNTY AMBULANCE PERMIT
LICENSURE FOR: July 2005 TO: July 2006
AMBULANCE SERVICE: Eagle County Health Service 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 July 26 and 29.2005 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 Comm;,,;ooeo; lov<mb~' 1990.
INSPECTORS: 4/v--
Kristin Diedrich, R.N.
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Lin a Maggiore, R.N. \. \J
CO
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EMERGENCY MEDICAL SERVICES
APPLICATION
AMBULANCE SERVICE LICENSE
Date of Application: 1J~(OS-
Name of Ambulance Services:
(owner or parent company) Eagle County Health Service District
Doing Business As: Eagle County Ambulance District
Address: P.O. 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 Will Be Served By This Company? Please Attach A Map Indicating
The Service Area.
Eastern portion of Eagle County from mile marker 154 on 1-70 to mile marker 190.
Then north and south to Routt and Lake county lines.
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List All Location (Central Station And Sub Stations) where ambulances
are to be located. Attach Zoning Authorization If Appropriate.
Edwards Builing (head<<uarters) 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
10
.
.
A SEPARATE Permit Request For Each Ambulance.
Provide Name And Address Of Your Insurance Carrier:
See attached Certificate of Insurance
Name Of Agent:
A IT ACH A CERTIFICATE OF INSURANCE TO THIS APPLlCA TION.
I HEREBY CERTIFY THAT THE INFORMA nON PROVIDED IN THIS
APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO
WILLFUL MISREPRESENTA nON OR F ALSIFICA TION.
DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE
INFORMA nON CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL
PROSECUTION.
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Signature of Notary
My Commission expires:~ -I
(For Office Use Only)
Date Received: -! -I_I Documents Checked:
Fee paidor8-- Receipt #:
Remarks: :MuJfRdlac Cmtf-liffd ~c2b ~2% ZoOS
Approval Recommended (Y/N): ~ Date Ref! rred to B.O.C.C.LI .iJJ 15J
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~ ISSUE DATI: (MMIDDt'YV)
7/1812005
PRODUCIlIl. nos CElt.T1FICATBIS ISS1JBD AS A NA TI'Ilk OF INFOaNATION ONL V AND CONFERS NO
Earl McFarland Insurance Agency, Inc. R1GH1'S UPON nm CIlIlllFICATIi HOI..DBR. nos CElt.llFICATB DOES NOT AMEND. I!XT1lND
OIl ALTBIl nm COVJ!RAGB AFFORI> BY nm POUCIBS BELOW.
dba VFIS of Colorado COMPANIES AFFORDING COVERAGE
128 6t1l St. Unit C COMPANY
LrITD A AAIC
Windsor, Colorado 81632 COMPANY
LrITD B
COMPANY
Eagle County Healtb Services District C
LE1TER
COMPANY
PO Box 990 D
u:rTJ:R
Edwards, Colorado 81632 E
THIS IS TO CE'RTIPY THAT THE POUCTES or INSURANCE USTED BILOW RA VI: Bn:I'lISSUED TO THE INSURED NAMED AllOVE POR THE POLICY PE1tIOD
INDICATED. NOTWn1ISTANDING ANY UQUIREMI'.NT, TOM OIl COI'IDmON or ANY CI:IHBACT OR OTHIII. DOCUMENT WITH u:sncr TO WHICH THIS
CERTlnCATI: MAY IlE ISSUED OR MAY nJlTAlN, 1tI:IINSURANCE AFFORDED BY THE roLICJES DESCRIIIED IIERI1N IS SUBJECT TO ALL THE TERMS
EXCLUSIONS AND CONDmONS or SUCH POLICIES. LIMITS SHOWN MAY SAVE HEN ItmUCED BY PAID CLAIMS.
co TYn or INSURANCE POLICY NUMIIU roUCY ErF. POLICY EXP. LIMITS
LTR DATI (MMIDDIVY) DAn (MMIDDIYY)
A GINUAL UUILITY VFIS- TR-0020273-3 1/1/05 1/1/06 GI!NDtAL AGGREGAn $ 3,000,000
~ COMM. GENERAL lJAJIn.rrv PROD .{;OMPlOP AGe. S 3,000,000
o CLAIMS MADE 1:8] OCCUlt PERS. "ADV. INJURY S 1,000,000
o OWNER'S" CONTRACT'S PROT. EACH OCCURItENCE S 1,000,000
0_ rnu: DAMAGE (0.. FIre) $I 000 000
MBD. EXPENSE (0.. Per) S S 000
AUTOMOBILE lJAJIlLITY VFIS- TR-0020273-3 1/1/05 1/1/06 COMlIND SlNGLI $1,000,000
I:8]ANY AUTO LIMIT
o ALL OWNED AUTOS BODn. Y INJURY S
(per P...-)
o SCm:DULED AUTOS
o HIRED AUTOS BODn.y INJURY $
o NON.oWNED AUTOS (per A_.)
o GARAGE UABILITV PROPERTY DAMAGE $
0
EXCESS LIABn.rrv
o umRILLA FORM
o 0THEJl THAN UMBUu.A FORM
WORKJ:RS' COMPENSATION
AND DISEASE POUCY LIMIT
EMPLOYER'S lJAJIWTY DISEASE-EACH EMP.
011fER
Management Liability VFIS- TR-0020273-3 1/1/0S 1/1/06 Eacb Occurrence $1,000,000
Aggregate $3,000,000
DESCRIPTION or OPERATlONSiLOCATIONSlVnDCLESlSPEClAL ITEMS
Purpose is to sbow coverages .
