LifeCare Application

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Application Category

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Application Type

Lifecare Renewal Application

The details of your previous LifeCare enrollment application have been loaded below for your convenience. Please make any necessary updates prior to submitting your renewal enrollment application.

Are you renewing LifeCare? If you are renewing your LifeCare membership, please click here to search for your application and to renew.

Please complete the LifeCare application enrollment form below to enroll in LifeCare. If you would prefer to mail in your completed enrollment form, please Download the LifeCare Application here.

Broker Name(Required)

Broker Phone Number(Required)

Primary Member Information

First Name(Required)

Middle Name

Last Name(Required)

Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Phone Number(Required)

Email Address

Date of Birth(Required)

Do you live within the Fort Wayne city limits?(Required)

Please select your Township

Spouse Information

Include Spouse?(Required)

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Spouse Show/Hide

First Name(Required)

Middle Name

Last Name(Required)

Date of Birth(Required)

Dependents

Dependents are single children living with you under the age of 26. Any/all dependents must be living with you or be claimed by you on your Federal Income Tax.

Include Dependent(s)?(Required)

Dependent Information

Name	Relationship	Date of Birth	Actions

There are no Dependents.

Authorization & Signature

This membership application must be signed by the Insurance Policy Holder or Authorized person if uninsured.

By signing, I authorize the release of any medical information, held by anyone necessary to process a claim, and further assign and authorize such payment to be made directly to TRAA, or my participating Allen County township ambulance service provider. I further acknowledge I have read and understand the items stated in the Coverages and Membership contract.

As additional consideration for my LifeCare membership, I agree to assign my ambulance benefits of my insurance contract rights to TRAA or the participating Allen County township ambulance service provider for any date of transport.

Signature(Required)

Application Fee Payment

Manual Payment Method

Payment Date(Required)

Payment Amount(Required)

Payment/Check #(Required)

Credit Card(Required)

Card Details

Cardholder Name

Billing Address(Required)

Same as Mailing Address

Billing Address(Required)

Street Address City State ZIP Code

LifeCare Membership Fee

Price: