United Methodist Volunteers in Mission, Western Jurisdiction


United Methodist Volunteers in Mission-WJ Insurance Application


First name                Middle                Last        

Birthdate (month/day/year) ____/____/____          Conference                 


Church (Name & City)                                 Pastor’s name        

Home Address                                         

         Street                City        State        Zip Code

Home phone                Cell                Email        


Beneficiary                Estate/will    Name                Relationship        

Date of Departure (mon/day/yr)___/___/___   Date of return ___/___/___        Total # days         


Sponsoring organization (church affiliation)                         


Anticipated project/host                                        


Release of Liability (this must be signed by Applicant for application to be valid and to receive insurance).  I understand that the United Methodist church, the General Board of Global Ministries, and the United Methodist Volunteers-in-Mission, Western Jurisdiction program assumes no liability for any personal harm or illness, or for loss of or damage to any property, that may come to me while serving as a person in mission. I, my heirs, personal representatives and assigns, hereby absolve the above named United Methodist groups and hold them 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         


Witnessed by                                 Date        

Coverage Level

Administration Fee





$15.00/ team member





$5.00/team member




Total # days____________ x ____________ +  _____________ = ____________ Total Due

                                 Days                      Rate                    Administration Fee


Submit form and payment to your team leader. Team leader will make payment by credit card or check per instructions on the UMVIMWJ Website:  http://umvimwj.com   Policy Details are also available at the website:  http://umvimwj.com