Sec.19a-180-3. Application for a license or certificate for a new or expanded emergency medical service

The applicant shall apply to the Office on forms provided by the Office. The application shall be notarized and shall include the following:

(a) The name, address and nature of the legal entity that will implement the proposed service;

(b) The name, address and telephone number of the individual responsible for making application;

(c) The trade name, department, corporation, association or partnership under which the provider is or shall do business. If the provider is a corporation, name, address and title of all officers;

(d) Name of parent and associated companies if any;

(e) Type of service requested;

(f) Locations of proposed principal place of business and/or branch places of business;

(g) Locations of health facilities and other ambulance providers within the proposed area to be served;

(h) Number and types of currently authorized vehicles;

(i) Number and types of new or expanded emergency medical services being requested;

(j) Geographic area and population to be served in implementing the proposed service;

(k) Source and volume of calls over the past 12 months for a currently licensed applicant;

(l) Total number of calls a currently licensed applicant refused over the past 12 months, and the circumstances for refusal;

(m) Source and volume of calls expected over the next 12 months;

(n) Average response times over the past 12 months for a currently licensed applicant;

(o) Evidence of paid-in working capital or binding credit agreement which equals six months operating expenses in the aggregate;

(p) Analysis of the improvement in cost effectiveness to the provider as a direct result of the proposed service;

(q) Analysis of how the proposed service would integrate with the current emergency medical service system;

(r) Proof of insurance or letter of intent for new services at levels required of by section 19a-180-2(d) of these regulations; and

(s) Any other information as may be included by the applicant;

(Effective December 15, 1983)