Extra Insurance Request Form

Extra Insurance Request Form
Registered Girl Scouts (Girls and Adults) are covered by accident activity insurance through Mutual of Omaha Insurance Co (Ba sic Coverage Plan 1). Non-members who are invited to attend a Girl Scout event or trip are covered under the Basic Coverage Plan 1. Extra Insurance is only needed for International Travel and if coverage for accident and sickness is needed. Each day of this trip must be covered, including travel days. This form with payment information and an itinerary (international travel), must accompany your Trip Approval Form three (3) weeks before the trip or event to give enough time to complete any missing training or paperwork.
Troop #:
Service Unit
Co-Leader's Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Destination/Location of Event*
Total Number of Participants*
Date: From*

MonthDayYear
Date
Date: To*

MonthDayYear
Date
Level of Coverage: Pick the Plan which you are submitting for*

Plan 3P: $0.70 per day per participant accident and sickness, primaryPlan 3PI: $1.17 per day per participant accident and sickness, international trips
Payment Calculation
Number of Participants*
Number of days (including travel days)*
x (multiply) by rate Plan:*

0.701.17
Final Cost ($5 minimum required by Mutual of Omaha)
Payment due

prevnext( X )
USD
Should be Empty:

Payment Calculation