Certificate of Insurance Request Form

Additional Insurance Request Form
This form is to be used by Volunteers. Option plans are available and are a secondary insurance coverage that will cover participants taking part in an activity or event. Additional Insurance is required for non-members that participate in any Girl Scouts activities. It is also required to purchase for any members that participate in any trips.

Please submit this form 30 days in advance of event or trip date.
Requester Information:
Service Unit #: *
Troop #: *
Requester's Name: *
Email Address: *
example@example.com
Type of Insurance Request: *

Event Insurance Extended Trip Insurance
Event Insurance Information:
Event Start Date *

- Month - Day Year
Date
Event End Date *

- Month - Day Year
Date
Name of Event: *
Event Location: *
Number to Insure: *
Extended Trip Insurance Information:

Trip must be approved prior to purchasing additional insurance for an extended trip.
Is this an international trip: *

Yes No
Trip Start Date *

- Month - Day Year
Date
Trip End Date *

- Month - Day Year
Date
Trip Details: *
Total Number of Participants: *
International Trip Details: *
If you have any further questions, please contact:

Lori Jackson at ljackson@gsnypenn.org or 1.855.213.8555 ext 2523
Should be Empty:

Additional Insurance Request Form