Volunteer Application

Volunteer Application

We’re excited you are interested in joining our team!

Please fill out the form below to be considered for a volunteer position.  Within the next couple of days you will receive a verification email from our staff letting you know which of our Regional Liaisons will be in contact to discuss volunteering with our program.

Contact us at claim@primaris.org if you experience any problems submitting your application.  Thanks again for your willingness to get involved.

Name (First and Last) (required)

Address (Personal Mailing) (required)

City (required)

State (required)

ZIP Code (required)

County (required)

Phone Number (XXX-XXX-XXXX) (required)

Phone Number Type (required)

Fax Number (optional)

Email Address (required)

Sex (required)

Date of Birth (required)

Ethnicity/Race (optional)
White, Non-HispanicBlack or African AmericanAmerican Indian or Alaska NativeAsianHispanic or LatinoNative Hawaiian or Other Pacific IslanderOther

How Did You Hear About CLAIM? (required)
Volunteermatch.comThis websiteFriend or relativeNewspaper or newsletterEmployerCLAIM Volunteer/Staff (please list name in "Specify Other" box)AmeriCorps Member (please list name in "Specify Other" box)Other

Specify Other

Positions I Am Interested
CounselorLeader in OutreachAdministrative SupportInterest SpecialistAmeriCorps Member

*CLAIM volunteers cannot work for insurance companies, have an insurance license and/or sell insurance for at least one year prior to volunteering. A person cannot potentially receive any financial gain from becoming a CLAIM volunteer counselor.

Are you currently working in the insurance industry? (required)

If no, have you in the past 12 months? (required)

If yes, what were your responsibilities?

Occupation (if retired, please note former occupation) (required)

If currently employed, who is your employer?

Language Skills

Education and Experience

Community Service Activities (include board memberships and all volunteer activities)

Why do you want to be a volunteer with CLAIM? (required)

Would you be willing to make a minimum commitment of six hours/month for six month? (required)

Have you ever been convicted of a felony?
(A Yes answer is not an automatic disqualification. A background check will be completed during training) (required)

If yes, please briefly explain.


Please list three references.

Reference One

Reference One Name (First and Last) (required)

Reference One Phone Number (required)

Reference One Email (required)

Reference One Relationship (how they know you) (required)

Reference Two

Reference Two Name (First and Last) (required)

Reference Two Phone Number (required)

Reference Two Email (required)

Reference Two Relationship (how they know you) (required)

Reference Three

Reference Three Name (First and Last) (required)

Reference Three Phone Number (required)

Reference Three Email (required)

Reference Three Relationship (how they know you) (required)