Southern Farm Bureau Casualty Insurance Company Child-Saver Program Order Form Please print clearly & legibly this is your shipping label. You MUST complete all lines to process order
Member Name County
Member No. and State
Required to process order
Please complete all lines and type name and address or print in black ink Daytime Name Phone #
Will UPS deliver to a: business residence
(In case of question about order)
Address
Please check one
(No po boxes accepted – Must use physical address) (City)
(State)
(Zip)
No choice of fabric pattern or color – item will be gender neutral CC123FSM Cosco Scenera Next Convertible Car Seat $25.00/co-pay per seat
22-491FSM Cosco Pronto High Back Booster Seat $15.00/co-pay per seat
2 modes of use Rear facing 5 – 40 lbs. Forward Facing 22-40 lbs. 5 harness heights 3 buckle locations Side Impact Protection 5 point harness with up front adjuster Removable Cup Holder
Forward Facing only 40 – 100 lbs. Removable, Fabric Pad Must use vehicle lap and shoulder belt Back removes for backless booster 40 – 100 lbs. Adjustable height positions Slide out cup holder
3 Seat Limit Qty
Model
Description
Total
CC123FSM
Cosco Scenera Next Convertible Seat
$25.00
22-491FSM
Cosco Pronto High Back Booster Seat
$15.00
Order Total Please make your check payable to: CHILD SOURCE Mail check or money order with order form to CHILD SOURCE: 305 Lake Road, Medina, OH 44256
Fax, phone orders & Credit Cards not accepted Please allow 2 – 3 weeks for delivery
ext 118
For questions regarding your order, call Child Source Customer Service @ 800-815-6330 **In order to serve you better, you must have your Farm Bureau member number ready when calling** Updated August 16, 2016