State of Ohio EMS
| |OHIO DEPARTMENT OF PUBLIC SAFETY | |
| |DIVISION OF EMERGENCY MEDICAL SERVICES | |
| | | |
| |LICENSE APPLICATION CHECKLIST | |
| |
|Use this checklist to make sure the application is complete before mailing. |
| |
|Only completed applications will be accepted. |
| |
|APPLICATION |
| Filled out completely with correct information, signed and dated. |
| Federal Tax ID Number or E.I.N. |
| |
|ATTACHMENTS |
| List of all Ambulette drivers and their date of hire (Ambulette Only). |
| Copy of blank trip / run report. |
| Color photograph of vehicle logo. |
| |
| CERTIFICATE OF INSURANCE |
| General Liability (Minimum $500,000 each occurrence and General Aggregate*). |
| Vehicle Liability (Minimum $350,000 combined single limit each occurrence or Minimum $100,000 bodily injury per person, $300,000 per accident, $50,000 property |
|damage per accident*). |
| Insureds name and address is the same as on the application and 30-day cancellation notice. |
| State Board of Emergency Medical, Fire, and Transportation Services listed as certificate holder on insurance documents. Certificate holder address is 1970 West |
|Broad Street, Columbus, OH 43223 OR P.O. Box 182073, Columbus, OH 43218-2073. |
| |
|FEES (see chart below) |
| Check or money order made payable to: Ohio Treasurer of State. |
| |
|FEE CHART - Fees are non-refundable and consist of License Fee + (Permit Fee x Number of Vehicles) |
| |
|*Example: Non-emergency medical service organization with 3 ambulettes |
|$100 License Fee + ($100 per vehicle fee x 3), $100 + $300 = Total Due $400 |
|EMERGENCY MEDICAL SERVICE ORGANIZATION |
|LICENSE FEE |$ 100 |
|and | |
|AMBULANCE PERMIT FEE (PER VEHICLE) | |$ |
|Number of Vehicles: x $200 = | | |
| | | |
| |0[p| |
| |ic]| |
| |0 | |
|MOICU PERMIT FEE (PER VEHICLE) | |$ |
|Number of Vehicles: x $200 = | | |
| | | |
| |0[p| |
| |ic]| |
| |0 | |
|NON-TRANSPORT VEHICLE FEE (PER VEHICLE) | |$ |
|Number of Vehicles: x $200 = | | |
| | | |
| |0[p| |
| |ic]| |
| |0 | |
|TOTAL DUE | |$ 0 = 0.00 “ |
| | |“300 |
| |100| |
| |[pi| |
| |c]1| |
| |00 | |
|NON-EMERGENCY MEDICAL SERVICE ORGANIZATION |
|LICENSE FEE |$ 100 |
|and | |
|AMBULETTE PERMIT FEE (PER VEHICLE) | |$ |
|Number of Vehicles: x $100 = | | |
| | | |
| | | |
| |0[pi| |
| |c]0 | |
|TOTAL DUE | |$ 0 = 0.00 “ “200 |
| | | |
| | | |
| |100[| |
| |pic]| |
| |100 | |
| |
|If we can assist you with this application or if you have any questions, please call us at (800) 233-0785. |
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