Mission Volunteers Office
475 Riverside Dr., Suite 330
New York, NY 10115
Tel (212) 870-3825
Website: http://gbgm-umc.org/vim

UNITED METHODIST VOLUNTEER IN MISSION (UMVIM) ACCIDENT INSURANCE APPLICATION
 Please print legibly in black or blue ink, and sign the Release of Liability. Couples must fill out separate forms. Reproduce as needed.

__Rev./ __Dr./ __Mr./ __Mrs./ __Ms.   ______________________________________________________
                                                                   First Name                           Middle Initial              Last Name

Birth date (month/day/year) ___/___ /___ Member Church (Name & City) __________________________
Home Street Address (including apartment #), or PO Box _______________________________________
City, State & Zip Code (+ additional 4 digit zip code if known)   ___________________________________
Phone # (_____) ______________________   E-mail address ___________________________________
Beneficiary: [ ]Estate/My Will  [ ]Name _______________________  Relationship to you ______________
Date of Departure (month/day/year) ____/____/____   Date of Return (month /day/year)  ____/_____/____
Sponsoring organization (e.g.,local church, Conf.) __________________ UMVIM project name ______________
Type of team:  Medical ____    Construction ____  Other (specify): ________________________________
Destination (if in the U.S., city & state; if abroad, name of country) ________________________________
Team Leader / Coordinator  1 ____________________________   2 ______________________________

These are legal statements, and you may wish to review them with an attorney:

 RELEASE OF LIABILITY (this must be signed BY APPLICANT for application to be valid & for applicant to receive insurance coverage)
I understand that the General Board of Global Ministries of The United Methodist Church assumes no liability for any personal harm or illness, or for loss of or damage to any property, that may come to me while I am serving as a United Methodist Volunteer in Mission, and I, my heirs, personal representatives and assigns, hereby absolve the General Board of Global Ministries of The United Methodist Church and hold it harmless from any claim or demand which I, my heirs, personal representatives or assigns might conceivably assert for any such harm, illness, loss or damage. I intend to be legally bound by this statement.


Signed  ______________________________________________________________                Date  ________ / ________ / ________
(If the volunteer is 21 years or less, both the volunteer's and a parent’s or guardian's signature are required)

Witnessed by  __________________________________________________________               Date   _______ / ________  / ________

PRIVACY RIGHTS
By my signature below, I consent to the recording and use of the personal data I am providing for the Mission Volunteers Database (MVDB), utilized by designated, password-authorized persons in GBGM, UM Committee on Relief (UMCOR), UM Volunteers In Mission (UMVIM), and MV programs. A voluntary service, the MVDB provides information for volunteer recruitment, placement, and communication, as well as insurance and statistical record-keeping. I may obtain a copy of and/or request the deletion of my data by contacting GBGM by signatured request. After seven (7) years of no data activity, my personal data may be deleted. I release GBGM and all MVDB-authorized users from all legal responsibility for the use of my personal data unless they have recklessly misused the information. For complete details regarding MVDB policies, please consult http://gbgm-umc.org/vim/mvdb/policy.htm.
Signed  ______________________________________________________________                 Date  ________ / ________ / ________
(If the volunteer is 21 years or less, both the volunteer's and a parent’s or guardian's signature are required)

NOTES: 1) This insurance policy is for participants in UMVIM work projects which are either listed in the Jurisdictional & Mission Volunteers websites (see http://gbgm-umc.org/vim/umvimmap.htm), Advance specials, or involve working with GBGM missionaries. 2) We try to accommodate applications up to the last minute, but please try to mail them 1 month before departure, in 1 batch (not separately), & pay with 1 check (not separate checks). Check should accompany applications. 3) Attach cover sheet stating a) team leader's or coordinator's name, address, phone, & email, b) destination, c) names & # of persons per each distinct set of dates of coverage (i.e. having same dates of departure AND return), as letter of coverage is drawn up per # of persons with same dates. 4) Make check payable to: General Board of Global Ministries, at $.75 per person per day, including days of departure & return (in subtracting departure from return date, add 1 to the difference to get correct # of days). 5) NO cancellations. 6) Don't fax applications. 7) Address envelope to: Mission Volunteers, Room 330, 475 Riverside Dr., New York NY 10115. 8) Team leader/coordinator will be sent a copy of our letter to insurance company for team coverage. (Revised 1/4/06)

Accident Insurance Policy
Issued to the Mission Volunteers Program Area
By the Federal Insurance Company of the Chubb Group
For Participants in United Methodist Volunteers in Mission (UMVIM) Projects

Note: There is a deductible of $250. This insurance policy is intended for those working in UMVIM projects, including travel to and from. UMVIM projects are defined as those projects which are either listed in the Jurisdictional & Mission Volunteers websites (see http://gbgm-umc.org/vim/umvimmap.htm), Advance specials, or involve working with GBGM missionaries. It is not intended for language study (except when required by the Individual Volunteer program) or non-work trips.

Cost of Coverage:  BEGINNING  JANUARY  1,  2005,  THE  COST  OF  COVERAGE  is  $0.75  PER  PERSON  PER  DAY,  including  day  of  departure  and  day  of  return.

Outline of Coverage:
Medical expenses for an injury due to an accident: If an accidental bodily injury results in an insured person requiring medical care and treatment, the policy will pay the reasonable and customary medical expenses of medically necessary medical services up to $10,000, subject to a deductible of $250. Medical services means the costs for medically necessary treatment by a physician or dentist, hospital room & board, use of an ambulance, drugs, medicines, diagnostic tests & x-rays, treatment performed by licensed medical professional (if hospitalization would have otherwise been required), rental of durable medical equipment like wheel chairs or hospital beds, prosthetic appliances, orthopedic appliances or braces. It does not apply to charges for which the Insured Person has no obligation to pay, eyeglasses, other vision & hearing aids, and artificial limbs.

Accidental death and dismemberment benefit: If accidental bodily injury causes the following losses w/i one year of the date of the accident which are not otherwise excluded, the policy will pay indicated percent of the principal sum of $60,000 for: loss of life, 100%; loss of speech & hearing, 100%; loss of speech & one of: hand, foot or sight of an eye, 100%; loss of hearing & one of: hand, foot or sight of an eye, 100%; loss of both hands, both feet, sight of both eyes or a combination of any two of a hand, a foot, or sight of an eye, 100%; loss of one hand, one foot, or sight of an eye, 50%; loss of speech or hearing, 50%; loss of thumb & index finger of same hand, 25%.

Medical evacuation & repatriation: If accidental bodily injury, disease or illness causes an insured person to require a physician-ordered medical evacuation and/or repatriation, the policy will pay for covered expenses incurred up to maximum amount of $100,000. The assistance services administrator, Medex Assistance Co., must approve evacuation/repatriation. Covered expenses include costs for evacuation, transportation, medical supplies & services, but not expenses incurred if travel is against advice of a physician, for the purpose of obtaining medical treatment or due to normal pregnancy or resulting child birth. Medex operates a 24-hour toll-free emergency telephone assistance service. To access emergency assistance services while traveling, please call one of the following emergency tel. #s: 1-800-527-0218 from w/i US, Canada, Puerto Rico or US Virgin Islands, or 410-453-6330 collect from anywhere else in the world. Maximum limit of insurance/aggregate: $500,000 per accident.

Exclusions: These include loss occurring while insured is in, entering or exiting any aircraft owned, leased or operated by his or her employer or on behalf of employer; loss occurring while insured is in any aircraft while acting or training as a pilot or crew member (this does not apply to passengers who temporarily perform pilot or crew functions in a life-threatening emergency); loss caused by or resulting from insured’s emotional trauma, mental or physical illness, disease, pregnancy, childbirth or miscarriage, bacterial or viral infection or bodily malfunctions (this does not apply to loss resulting from bacterial infection caused by an Accident or from Accidental consumption of a substance contaminated by bacteria); loss resulting from suicide, attempted suicide or loss intentionally self-inflicted; loss caused by or resulting from declared or undeclared war, but war does not include acts of terrorism; loss while insured is participating in military action with Armed Forces of any country or established international authority.

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