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 (Basic Coverage Plan 1). For all trips longer than two (2) nights, international trips and trips/activities where non-Girl Scouts are in attendance extra insurance must be obtained. Each day of the trip must be covered, including travel days. This from along with payment and an itinerary must be submitted four (4) weeks before the trip/activity to give enough time to complete any missing training or paperwork.
Troop #:
Service Unit
Co-Leader's Name *

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

Area Code Phone Number
Mailing Address

Street Address

Street Address Line 2

City State / Province

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

Month Day Year
Date
Date: To *

Month Day Year
Date
Level of Coverage: Pick the Plan which you are submitting for *

Pan 2: $0.11 per day per participant accident Plan 3E: $0.29 per day per participant accident and sickness, supplemental Plan 3P: $0.70 per day per participant accident and sickness, primary Plan 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: *

0.11 0.29 0.70 1.17
Final Cost ($5 minimum required by Mutual of Omaha)
Payment due

prev next ( X )
USD
Should be Empty:

Payment Calculation