<p> AGREEMENT FOR AMBULANCE SERVICES</p><p>1. ______hereby agrees to provide ambulance services, in the common meaning of those words, to the Town, whenever called upon to do so for the duration of this agreement.</p><p> a. ______shall supply ambulance vehicles, together with the necessary manpower to utilize said equipment and agrees to maintain at least one station within the Town of ______to house-said vehicles and other necessary fire and rescue apparatus.</p><p> b. ______shall promptly respond, upon being notified by the ______County Emergency Dispatcher, to any location of the east side of the river within the Town of ______boundaries marked by the map included with this contract, with the necessary ambulance apparatus as well as sufficient manpower to operate said apparatus, to render emergency medical services at the scene of such emergency.</p><p> c. Rescue services shall include both emergency medical care on the scene of an emergency, rendered by ______State certified emergency medical technicians as well as transportation by ambulance to medical facility by ______EMT’s. Rescue services shall include but are not limited to instances involving trauma, medical emergencies, automobile accidents and water and ice rescue operations, Rescue services shall not include emergency response to incidents involving known “hazardous materials” as that term is commonly used in the fire service.</p><p> d. Services shall also include mutual aid response by fire departments from surrounding communities to assist ______should ______request aid from such departments. The need for such response shall be in the sole discretion of the ______Chief or his designees. There shall be no additional charge to the Town for mutual aid response.</p><p>2. ______agrees to provide State certified Basic level E.M.T.s and on each of its ambulance calls and further agrees to provide at least one State certified Intermediate Level E.M.T. on each ambulance call to provide advanced life support care, if such level of care is necessary. ______agrees to educate and finance the education of all its E.M.T.s and to also finance their continuing education to ensure that they maintain their respective State certifications. ______further agrees to secure vehicle, liability, property damage, and errors and omissions insurance for and all actions of the said E.M.T.s, officers, and ______as a whole.</p><p>3. ______shall obtain and maintain in full force and effect during the term of this contract and pay the premium thereon for the following policies of insurance.</p><p>A. Workers Compensation policy</p><p>B. Commercial General Liability policy with a combined single limit of not less than $2,000,000 per occurrence for bodily injury, personal injury and property damage.</p><p>C. Automobile Liability policy for all vehicles with a combined single limit of not less than $2,000,000 per occurrence for bodily injury and property damage.</p><p>D. Medical Malpractice policy for the rescue and ambulance services provided for in this agreement with a limit of not less than $2,000,000 per occurrence.</p><p>E. A certificate of insurance shall be sent to the Town showing the above requirements have been complied with, providing for written notice to the town 30 days in advance of full or partial cancellation. The normal ACORD cancellation notice is not acceptable unless the phrases “endeavor to” and “but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives” are deleted.</p><p>F. Memorandum copies of the insurance policies shall be provided to the town upon request. 4. ______shall charge a fee to the town of $____ for each patient transported by ______to a medical facility. ______shall charge the town an additional $_____ for each such patient transported to a medical facility who requires the use of advanced life support services rendered by a ______State certified Intermediate Level. The town shall have the right to recoup said monies paid to ______from any such patient. There shall be no charge for any patient not transported for a rescue response unless Advanced Life Support treatment is rendered to a patient by ______, for which a charge of not less than $____ nor more than $____ will be made for services rendered. There shall be no charge for any fire response that does not result in a patient being transported to a medical facility.</p><p>5. In consideration for the above services, the town agrees as follows:</p><p> a. The town shall agree to monthly payment in full for patient transports. Any monies allotted to the town by Federal or State programs which are specifically designated for use by ambulance providers shall not be included in said service fee nor shall they serve to reduce said service fee provided hereunder.</p><p> b. The town also agrees that it will not contract with other public or private ambulance companies for ambulance services within the boundaries specified on the map included with this contract for the duration of the contract which will begin January 1, 20__ and cease December 31, 20__</p><p>Dated in ______, ______this______day of ______, 20__.</p><p>By the Town:______Title: ______</p><p>By(_____): ______Title: ______</p>