<p> United Methodist Volunteers In Mission – North Central </p><p>Jurisdiction</p><p>UMVIM-NCJ 910 4th Street, Suite G Brookings, SD 57006 605-692-3390 /Fax: -0909 [email protected] Christian love in action! </p><p>International and USA Medical and Accident Insurance CMA Agency, Georgia</p><p>United Methodist Volunteers In Mission – North Central Jurisdiction has contracted with CMA to offer this Accidental and Medical Insurance Policy. Seven Corners, Carmel, IN is the program administrator.  The coverage option is for $10,000  To review the policy go to: www.umvim-ncj (under the FORMS menu)</p><p>Instructions (Note: Forms and payment are due 2 weeks prior to departure) 1. Complete the top section with team and leader information 2. Fill out the roster form (check that all spelling and birthdates are correct) Use another page if more members need to be added 3. Calculate insurance costs in the chart at the bottom of the form $1.55 per day per traveler (extra lines are for travelers with different trip dates) $10 per person registration fee</p><p> Add lines A through D for total premium due 4. Make check out to UMVIM-NCJ 5. Fill out the roster form (check that all spelling and birthdates are correct) 6. At least 14 days prior to departure, mail ______insurance form ______check with total premium due to: Lorna Jost, UMVIM-NCJ, 910 4th St., Suite G, Brookings, SD 57006 We can also accommodate VISA and MC. Call 605-692-3390. Checks are preferred.</p><p>You may email the completed form to <[email protected]> as long as the check is in the mail! Call 605-692-3390 with any questions.</p><p>UMVIM-NCJ / 910 4th St. Suite G / Brookings, SD 57006 / [email protected] / 605-692-3390 Lorna Jost UMVIM-NCJ Coordinator</p><p>United Methodist Volunteers In Mission - North Central Jurisdiction </p><p>Team Leader: Destination: Team Leader Address: Email: Number on Team: Phone #: Departure Date: Alternate Phone # Return Date: Fax #: Number of Days: Type of Mission:</p><p>Name (List Team Leader 1st) Date of Birth Travel dates if different from above 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.</p><p>Trip Premium Calculator (A., B., and C. are for team members with different travel dates) Coverage Coverage Cost / Day / No. of No. of Travel Days Premium Option Limit Traveler Travelers (Include departure & return) Amount A. Insurance $10,000 $1.55 X X = B. Insurance $10,000 $1.55 X X = C. Insurance $10,000 $1.55 X X = D. Registration fee Total Vols = X $10.00 = Total Due (Entire payment is due prior to trip departure.) A + B + C + D =</p>