Activity Insurance Purchase Form

Activity Insurance Purchase Form

For Girl Scouts of Michigan Shore to Shore Troops/Service Units Only
This form is for Girl Scouts of Michigan Shore to Shore (GSMISTS) troops or service units ONLY. If your troop does not belong to Girl Scouts of Michigan Shore to Shore please contact your council directly to find out their process to purchase additional activity insurance.*

I Understand
To purchase additional activity insurance, complete and submit this form with the appropriate fee at least 4 weeks before the activity/trip date.
Trip Start Date*

MonthDayYear
Date
Trip End Date*

MonthDayYear
Date
Your purchase does not fall withing the minimum approved timeline and cannot be completed at this time.
Plan Information:

Plan 3P Accident Plus Sickness Insurance

$0.70 per participant, per calendar day; $5.00 minimum enrollment

· Plan 3P covers accident and sickness benefits when illness/symptoms occur while coverage is in place.

· Primary coverage.

· All claims are subject to review by Mutual of Omaha.

Plan 3PI Accident and Sickness Insurance for International Trips

$1.17 per participant, per calendar day; $5.00 minimum enrollment

· Provided by AXA Assistance-USA and Mutual of Omaha.

· Covers accidents and illnesses during an international trip.

· Complete roster of participants including age must be completed and submitted with application.

· All claims are subject to review by Mutual of Omaha.
First and Last Name*

First NameLast Name
Troop Number*
Service Unit Number*
Phone Number*

Area CodePhone Number
Contact Email*
example@example.com
Name of Activity/Trip*
If your activity/trip takes place at multiple locations, please use the address that you are staying at the majority of the time. (for cruises or train travel day trips, please use the port/station your will be departing from)
Activity/Trip Information*

Location Name

Street Address Line 2

CityState / Province

Postal / Zip Code
Coverages Offered for Purchase
Choose the plan that is best for your activity/trip

Plan 3P: Primary accident and sickness coverage for troop travel for trips and activities ($0.70 per person, per day). This is a great option for longer trips.

Plan 3PI: Accident and sickness coverage for participants in international trips ($1.17 per person, per day).
Choose Insurance Plan*
Number of Participants*
Number of Days
calculated from dates given above
Plan Total
Min Fee
Final $
Signature*

Clear
Today's Date*

MonthDayYear
Total Due: ($5.00 minimum)

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USDActivity Trip Insurance

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Activity Insurance Purchase Form

Coverages Offered for Purchase