AMR Air Ambulance Aircrafts

AMR Air Hawaii Membership Application

Membership covers all listed members of your immediate family so long as they remain residents in your household and are a legal dependent.

Please select a membership plan below. Only one plan may be selected.

1-Year Family With Insurance $30.00
1-Year Family Without Insurance $60.00
2-Year Family With Insurance $50.00
2-Year Family Without Insurance $80.00
3-Year Family With Insurance $70.00
3-Year Family Without Insurance $100.00

BILLING ADDRESS

Physical Address (if different than Billing Address)

PHYSICAL ADDRESS

MEMBER

Membership covers all listed members of your immediate family so long as they remain residents in your household and are a legal dependent. ONLY LEGAL DEPENDENTS OF THE PRIMARY MEMBER ARE ELIGIBLE.
 

More than 6 household members, please contact us at 808.487.4900 to complete your membership application.
 

ADDITIONAL HOUSEHOLD MEMBER

ADDITIONAL HOUSEHOLD MEMBER

ADDITIONAL HOUSEHOLD MEMBER

ADDITIONAL HOUSEHOLD MEMBER

ADDITIONAL HOUSEHOLD MEMBER

ADDITIONAL HOUSEHOLD MEMBER