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
629 Allendale/Barnwell/Bamberg
631 Southern Beaufort
634 Cheraw/Chesterfield/Jefferson/Pageland
635 Marlboro County
636 Northern Beaufort
637 Colleton County
638 Western Horry
639 South Strand
640 Myrtle Beach
641 Northern Horry
642 Dillon
643 Orangeburg/Calhoun
644 Clarendon County
645 Marion
646 Florence
649 Georgetown
650 East Cooper
651 Hartsville/Lee County
652 Darlington/Lamar
655 Kingstree/Lake City/Johnsonville/Hemmingway
657 Charleston Peninsula
658 West of the Ashley
660 Greater Dorchester County
662 Greater Berkeley County
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
*
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:
*
0.70
1.17
Final Cost ($5 minimum required by Mutual of Omaha)
Payment due
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( X )
USD
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