Optional Trip Insurance

Optional Trip Insurance - Plan 3PI

Enrollment Form for Optional Accident plus Sickness Insurance for International 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 NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please provide accident plus sickness insurance for International Trip 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.

Trip 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 3PI Insurance - Minimum Charge $5.00

Premium Each Day at $1.17Total Number of Participants multiplied by (x) number of days = Quantity for Premium Insurance

$1.17 Quantity

Minimum ChargeDifference to Minimum Charge of $5.00

$0.01 Quantity

Total

$0.00

Payment Method
Credit	Express

ATTENTION TROOP LEADER: Please list the roster of girls included in this enrollment form. (See format on instruction sheet.) Please prepare and bring a list of emergency parental, guardian or other personal contacts and their telephone numbers for all participants with you during the trip.*
Should be Empty:

Optional Trip Insurance - Plan 3PI