Optional Accident Insurance

Optional Accident Insurance - Plan 2

Enrollment Form for Optional Accident Insurance for Girl Scout Activities or Events
1. This form MUST be received in the council office with payment at least two weeks prior to your event.

2. Once completed enrollment form is received by Girl Scouts of Central Indiana, the council will submit your enrollment information and premium to the insurance company. Council approval is required - troop leaders/volunteers should not submit emrollments directly to insurance company.

3. There is a $5.00 minimum charge.
Troop or Service Unit *
Troop or Service Unit Number *
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Please provide accident insurance to cover all enrolled partipants in the following approved, supervised Girl Scout activities (except statutory employees covered under workers' compensation)

Several events may be included on one enrollment form to meet the minimum.

Schedule of Event(s) *

	Name and Location of Event	Beginning Date	Ending Date	Number of Participants	Number of Days	Total Participants x Number of Days
Event
Event
Event
Event

Plan 2 Insurance - Minimum Charge $5.00

Premium Each Day at $.11 Total Number of Participants multiplied by (x) number of days = Quantity for Premium Insurance

$ 0.11 Quantity

Minimum Charge Difference to Minimum Charge of $5.00

$ 0.01 Quantity

Total

$ 0.00

Payment Method

Optional Accident Insurance - Plan 2