Southern Farm Bureau Casualty Insurance Child-Saver Program Order Form Please print clearly & legibly. This is your shipping label. You MUST complete all lines to process order.
Farm Bureau Member #
State (Required to process order)
Company Name
Daytime Phone #
(if applicable)
(In case of question about order)
Name Address (NO PO Boxes accepted - Must use physical street address)
(City)
(State)
(Zip)
Rear Facing 5 - 35 lbs; Forward Facing 22-40 lbs; 5 point harness system; Removable, padded fabric pad: Up Front harness adjustment:
Forward facing only; 40 - 80 lbs; Removable, padded fabric pad; Removable cup/juice holder; Must use vehicle lap & shoulder belt
Color is factory selected
22-120FSM Convertible Car Seat
Color is factory selected
22-214FSM High Back Booster Seat
*Limit (3) Car Seats and (3) Booster Seats per membership Member Price
Model
Description
22-120FSM
Cosco - Convertible Seat
$25.00
22-214FSM
Cosco - High Back Booster Seat
$15.00
Quantity*
Total Cost
Total Please make your check payable to:
Send your check/money order & order form to:
Mercury Distributing
Mercury Distributing
Please allowup upto tothree three(3) (3) Pleae allow weeks for for delivery delivery weeks
7001 Wooster Pike Medina, OH 44256 For questions regarding your order, call Mercury Distributing Customer Service Dept. at 800-815-6330 ext 118 **In order to serve you better please have your Farm Bureau member number ready when calling**