Get Mi Bhs-ems-0092 2005

The MI BHS-EMS-0092 is a vital document for life support agencies in Michigan that certifies insurance coverage. This guide will assist you in completing the form online accurately and efficiently.

Follow the steps to successfully complete the MI BHS-EMS-0092 form online.

1. Click ‘Get Form’ button to access the document and open it in your preferred online editor.
2. In the section labeled 'NAME OF INSURED/COVERED', enter the full legal name of the entity or person for whom the insurance is provided.
3. Provide the 'ADDRESS OF INSURED/COVERED', including the street address, ensuring you include details such as suite numbers or building names if applicable.
4. Fill in the 'CITY', 'STATE', and 'ZIP' code corresponding to the address provided in the previous step.
5. For the 'POLICY NUMBER', input the reference number that identifies the insurance policy for the life support vehicle.
6. Enter the 'EFFECTIVE DATE' of the policy, indicating when the coverage starts.
7. Specify the 'EXPIRATION DATE', noting when the policy coverage will end.
8. Input the 'limits of liability' for bodily injury coverage, specifying the coverage amount for 'BODILY INJURY COVERAGE FOR EACH PERSON', 'BODILY INJURY COVERAGE FOR EACH CRASH', and 'PROPERTY DAMAGE COVERAGE FOR EACH CRASH'.
9. Indicate whether this is a fleet policy by checking the box for 'Yes' or 'No'. If 'No', attach a list of all life support vehicles, including details such as year, make, type, and vehicle identification number.
10. In the 'NAME OF COMPANY' section, enter the name of the insurance or participating plan provider issuing the certificate.
11. Fill in the 'AGENT'S NAME' and 'AGENT'S ADDRESS', making sure to include city, state, and ZIP code.
12. Finally, the authorized representative should sign in the provided area and include the date to confirm the information is accurate.
13. After completing all fields, save changes, download, print, or share the form as necessary.

Complete the MI BHS-EMS-0092 online today to ensure your life support agency is properly covered.