Court Referred Alternative Sentencing Volunteers Program

For Insurance Brokers Accessing the Volunteers Insurance Service (VIS®)

Court Referred Alternative Sentencing Volunteers Program

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We wish to apply for membership in VIS® and secure volunteer insurance on behalf of our customer through The CIMA Companies, Inc.

INSURANCE AGENCY
(Please show full name of agency):

ADDRESS:

CITY:

STATE:

ZIP CODE: -

PHONE: - -

FAX: - -

EMAIL ADDRESS:

IF YOU ALREADY ARE AN ACTIVE AGENCY WITH CIMA, PLEASE PROVIDE YOUR AGENCY CODE HERE (YOUR ACCOUNTING DEPARTMENT MAY HAVE THE CODE, OR CALL OUR VOLUNTEERS INSURANCE SERVICE STAFF AT 800.222.8920 TO OBTAIN THE CODE.) YOU WILL ALSO NEED TO PROVIDE YOUR AGENT NAME FURTHER DOWN THE SCREEN.

IF YOU ARE NOT ALREADY AN ACTIVE AGENCY WITH CIMA, PLEASE COMPLETE THE FOLLOWING INFORMATION.
(EITHER THE AGENCY CODE OR THE FOLLOWING INFORMATION IS REQUIRED, IN ORDER TO COMPLETE THIS APPLICATION):

PLEASE CHECK ONE:

INDIVIDUAL/SOLE PROPRIETOR PARTNERSHIP

CORPORATION OTHER

TAX ID NUMBER (IF COMMISSIONS ARE PAID TO CORPORATION OR PARTNERSHIP):

SOCIAL SECURITY NUMBER (IF COMMISSIONS ARE PAID TO INDIVIDUAL OR SOLE PROPRIETORSHIP):

PLEASE CHECK HERE IF YOU WOULD LIKE FOR CIMA TO SEND YOU A W-9 FORM SO YOU DO NOT NEED TO PROVIDE YOUR SOCIAL SECURITY NUMBER ON THIS APPLICATION (THE APPLICATION IS A SECURE FORM):

Your Professional Liability Insurer:

Your Professional Liability Policy Number:

POLICY EXPIRATION DATE: formatted [mm/dd/yy]

Agency LICENSE NUMBER FOR STATE IN WHICH INSURANCE IS BEING REQUESTED:

AGENCY LICENSE EXPIRATION DATE: formatted [mm/dd/yy]

AGENT NAME:

AGENT LICENSE NUMBER FOR STATE IN WHICH INSURANCE IS BEING REQUESTED

AGENT LICENSE EXPIRATION DATE: formatted [mm/dd/yy]

SPONSORING NONPROFIT ORGANIZATION USING THE VOLUNTEERS:

MAILING ADDRESS:

STREET ADDRESS:(Required by state insurance commissions.)

CITY:

STATE:

ZIP CODE: -

PHONE: - -

FAX: - -

CONTACT PERSON AT SPONSORING NONPROFIT ORGANIZATION:

TITLE:

EMAIL ADDRESS:

Do you perform any overseas business activities? Yes No

If yes, do your overseas business activities breach any U.S.A. Sanctions/Regulations? Yes No

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.

MONTH YOU WISH COVERAGE TO START:

	No. of Volunteers (provide estimate)	Rate	Annualized Premium	Prorated Premium

Accident Insurance		$9.85	$	$
				$100.00 MINIMUM PREMIUM - NOT PRORATED
VIS Membership Fee			$ 140.00	$ 140.00
TOTAL			$	$
			(ANNUALIZED)	(THIS AMOUNT DUE NOW)

NOTICE TO ALL CUSTOMERS: By applying for this insurance, the applicant also is applying for membership in Volunteers Insurance Service Association, Inc. a risk purchasing group formed and operating pursuant to the Liability Risk Retention Act of 1986(15 USC 3901 et seq.).

NOTICE TO CALIFORNIA CUSTOMERS: License #0B01377, #0G99581 and #0I84209, CIMA Companies Insurance Services. License #0G98538 and #0G99581, XS Insurance Services.

NOTICE TO KENTUCKY CUSTOMERS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

NOTICE TO RHODE ISLAND CUSTOMERS: This insurance contract has been placed with an insurer not licensed to do business in the state of Rhode Island but approved as a surplus lines insurer. The insurer is not a member of the Rhode Island insurers insolvency fund. Should the insurer become insolvent, the protection and benefits of the Rhode Island insurers insolvency fund are not available.

NOTICE TO TEXAS CUSTOMERS: The insurer for the purchasing group may not be subject to all the insurance laws and regulations of your state. The insurance insolvency guaranty fund may not be available to the purchasing group.

NOTICE TO WYOMING CUSTOMERS: The insurer with which the surplus lines broker places the insurance is not licensed by this state and is not subject to its supervision. In the event of the insolvency of the surplus lines insurer, losses will not be paid by the state insurance guaranty association.

To submit your application online: Note the amount that is due now, so you can write a check to follow up the application. On the memo line of your check, write the name of the sponsoring organization, just as it appears on the application. Then just press the SUBMIT button, and send your check to us at the address below.

To submit your application by mail: Press the PRINTER FRIENDLY VERSION button, print your application, and sign it (IMPORTANT). On the memo line of your check, write the name of the sponsoring organization, just as it appears on the application. Then send the application and the check to the address below.

Volunteers Insurance Service®
2750 Killarney Drive, Suite 202,
Woodbridge VA 22192

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