ABCDEFGHIJKLMNOPQRSTUVWXYZAA
1
 2026 INTERNATIONAL Accident & Medical Coverage Enrollment Form for Missions Journeys
United Methodist Volunteers In Mission - Western Jurisdiction
2
3
4
Distination City : Country:Types of Coverage
5
Project:Type of Mission:Bronze - $25,000 $2.25/day
6
Team Leader: Team Leader Address:Bronze** $2.75/day
7
Silver - $50,000 $2.50/day
8
Team Leader Email:Team Leader Phone: Silver** $3.00/day
9
Sending Church/District:Sending Conference:Gold $100,000 $2.75/day
10
Gold ** $3.35/day
11
** With Adventure Sport Rider valid for 64 and younger
12
Gold IQ 80+Senior $20,000$3.85/day
13
Traveler Information
14
15
First NameLast NameDate of BirthGender (M or F)Country of ResidenceCountry of CitizenshipDeparture DateReturn DateCoverage DaysCoverage Type Coverage RateInsurance Cost + $15 Admin. fee per member Email AddressPhone NumberAge
16
Example
JohnDoe7/1/1975FUSUS1/1/20241/12/202412$2.75 $48.00JDoe@myemail.mop444-555-666651
17
1Coverage Type
18
2Coverage Type
19
3Coverage Type
20
4Coverage Type
21
5Coverage Type
22
6Coverage Type
23
7Coverage Type
24
8Coverage Type
25
9Coverage Type
26
10Coverage Type
27
11Coverage Type
28
12Coverage Type
29
13Coverage Type
30
14Coverage Type
31
15Coverage Type
32
0.00
33
34
INSTRUCTIONS
35
1. Email completed form to umvimwj@gmail.com. Use a second form if needed.
36
2. Wait for confirmation that your form is complete and correct.
37
2. Use PayPal (https://www.paypal.com/donate/?hosted_button_id=ZF6SLMETRARQA) or make check payable to UMVIM WJ.
38
3. If paying by check, mail check AND printed form to: UMVIM WJ, Claudia Davis, 725 Middlemas Road, Helena MT 59602
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100