Court Referred Alternative Sentencing Volunteers Program

We wish to apply for membership in VIS® and secure insurance for our volunteers through the CIMA Companies, Inc.

SPONSOR:

MAILING ADDRESS:

Street address*

(Required by state insurance commissions.)

City

State/Region

Zip Code

Phone number

Fax number

CONTACT PERSON:

TITLE:

EMAIL ADDRESS:

DO YOU PERFORM ANY OVERSEAS BUSINESS ACTIVITIES?

Yes

IF YES, DO YOUR OVERSEAS BUSINESS ACTIVITIES BREACH ANY U.S.A. SANCTIONS/REGULATIONS?

Yes

DESCRIPTION OF SERVICES TO BE PERFORMED BY VOLUNTEERS:

HOW DID YOU HEAR ABOUT OUR PROGRAM?

When we receive your completed application and payment, coverage will be effective the first day of the following month, unless you prefer a later month. The policies expire July 1. Therefore, the premium you pay now will be a prorated amount covering only the period between your effective date and next July 1 (we will send a renewal application).

In the following section, first indicate the month when you wish coverage to begin (it must be a future month). Then, fill in the number of volunteers. The annualized premium and prorated amount will be calculated for you and shown in separate columns. The total amount due now, including the Volunteers Insurance Service membership fee, also will be shown.