Volunteer Form - Tri-State Paralyzed Veterans of America

Volunteer Status(Required)

New Volunteer

Reactivating Volunteer

Current Volunteer - Updating Information

Volunteer Number (if available)

Date

Chapter Name(Required)

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Gender

Male

Female

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Email(Required)

Please provide the following information if you use your personal vehicle for volunteer-related duties.

Driver's License #

State Held In

EXCESS AUTOMOBILE LIABILITY INSURANCE

Excess automobile liability insurance provides coverage to protect all active registered volunteers who use their personal automobiles for program-related duties. This insurance is over and above their personal auto insurance and only volunteers maintaining required personal liability insurance are eligible for coverage. The volunteer will automatically be covered by this insurance if they have provided a driver’s license number and the state in which it is held, when filing out their Volunteer Activation Form. If they do not provide this information they are not entitled to this insurance. If the volunteer enters an inactive status they will not be eligible for this insurance until their status is reactivated.

Waiver

I hereby affirmatively waive coverage under the Business Travel Accident Program (see next page).

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NATIONAL OFFICE USE ONLY

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Volunteer Identification Number

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Processed By:

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Process Date

BUSINESS TRAVEL ACCIDENT PROGRAM (BTAP)

This insurance provides 24-hour business travel accident coverage while the volunteer is away from the office performing official PVA business. All registered PVA volunteers are automatically covered under Class III, in accordance with PVA’s insurance policy. The BTAP form, naming the beneficiary(ies) can be submitted anytime to National Office. The volunteer will remain insured until they are terminated or become inactive. Volunteers can change their beneficiary(ies) anytime by submitting a new BTAP

Affiliation

PVA Committee Member

PVA National Employee

Chapter Volunteer

National Director

Executive Committee

Chapter Employee

Other Member

Volunteer Number (if known)

Type of Member (if Other)

DESIGNATION OF BENEFICIARY

Settlement of the proceeds payable under the terms of this policy by reason of death of the insured shall, subject to the applicable provisions printed below, be made in one sum to the beneficiary(ies) herein designated, EXCEPT as may be otherwise indicated by an ''X'' or check mark in the box preceding 1 below. Please type or print.

Payment Proceedings

1. Pay proceeds in one sum to THE ESTATE OF THE INSURED.

2. Pay proceeds to the following beneficiary(ies)):

Name

Relationship to the Insured

Name

Relationship to the Insured

Name

Relationship to the Insured

Any amount payable to a beneficiary shall be paid to the beneficiary(ies) designated by the insured, except that, unless otherwise specifically provided by the insured in his/tier beneficiary designation: (a) If more than one beneficiary is designated, the designated beneficiaries shall share equally. (b) If any designated beneficiary predeceases the insured, the share which such beneficiary would have received if surviving the insured shall be payable equally to the remaining designated beneficiary or beneficiaries, if any, who survive the insured. The General Provisions of this policy shall be considered as part of this Beneficiary Provision where applicable.

Signature of Insured

Date