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.
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.
Maximum number of dependents reached.
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.
