Tri-State PVA — Paralyzed Veterans of America

(503) 362-7998 TriStatePVA@TriStatePVA.org

Volunteer Status *

New Volunteer

Reactivating Volunteer

Current Volunteer - Updating Information

Volunteer Number (if available)

Date *

Chapter Name *

First Name *

Last Name *

Date of Birth *

Gender

Male

Female

Address *

Street Address

Address Line 2

City

State

ZIP Code

Phone Number

Email *

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.

I hereby affirmatively waive coverage under the Business Travel Accident Program.

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.

Affiliation

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 be made in one sum to the beneficiary(ies) herein designated.

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

Pay proceeds to the following beneficiary(ies):

Beneficiary 1 Name

Relationship to Insured

Beneficiary 2 Name

Relationship to Insured

Beneficiary 3 Name

Relationship to Insured

Signature of Insured

Date

Volunteer Activation Form

Excess Automobile Liability Insurance

Business Travel Accident Program (BTAP)

Designation of Beneficiary