Forms

ENROLL


For residents moving into an apartment complex, nursing home or live outside the City limits but within the Broken Arrow fenceline: 

If you would like to enroll in LifeRide, please complete the enrollment form between August 1 and August 31 and submit with your payment to LifeRide Program, City of Broken Arrow, PO Box 610, Broken Arrow, OK 74013.

If you are a new utility customer, you may sign up for LifeRide benefits when you open a new utility account with the City of Broken Arrow.

Download New Enrollment Form (PDF)
 
If you are a current utility customer and would like to enroll in LifeRide during the enrollment period, use the LifeRide monthly enrollment form.

Download Monthly Enrollment Form (PDF) 
  

OPT-OUT


If you would like to opt-out of LifeRide, opt-out forms must be submitted between August 1 and August 31 each year. Forms will be available on this page August 1, 2017. Complete the form and submit it to Utility Customer Service. Residents may also complete the form at the Utility Customer Service office located at 116 E. Dallas Street, Broken Arrow, OK 74012.

Please keep in mind that residents who opt-out of LifeRide will be responsible for paying any out-of-pocket expenses for ambulance services, after a claim has been submitted to the insurance provider. An individual without medical coverage will be responsible for the entire ambulance bill, which costs an average of $1,500. LifeRide members, however, pay nothing after a claim is submitted to the health insurance provider.

Download Non-Participation Form (PDF)
   

LANDLORDS


Landlords are required to notify all tenants, in writing, of the property’s LifeRide nonparticipation status, prior to the start of the next program year or upon entering into an initial lease agreement with the tenant, whichever is earlier. Landlord must then file written documentation signed by the tenant, which acknowledges the apartment complex is not participating in LifeRide. Read important information for landlords here.

Download Resident Notification Form (PDF)
 
Landlords must provide to the City on or before July 31 each year, the total number of residential living units owned or operated.

Download Certification of Living Units Form (PDF)
 
If you have any questions not answered in our FAQs or would like to learn more information on the LifeRide program, please call 918-259-6595 or email liferide@brokenarrowok.gov.