Additional Insurance Order Form

As of October 1, 2023, GSUSA no longer requires additional insurance purchases for domestic Girl Scout activities where non-members are present.  All domestic Girl Scout events are now automatically insured to cover accidents for all participants, member and non-member. 

Please submit this form if:

• Your group is traveling internationally
  OR
• You would like to add sickness insurance to any Girl Scout trip or event (for members and non-members)

Your payment is due with the submission of this request via the online credit card payment portion of this form.

To receive insurance coverage, GSMW must receive this form no later than 14 business days prior to your trip or event. Late submissions may result in an un-insured trip or event. GSMW cannot approve international trips without an additional insurance purchase. 

Please choose the insurance plan below that best suits your needs. To calculate the total cost for your group, please follow the example.

Example: You have 5 partcipants attending an international trip for 3 calendar days. 

5 Participants x $1.17 Plan 3PI = $5.85 x 3 calendar days = $17.55 Total Cost 

IMPORTANT NOTE: After your submission, this calculation will be confirmed by our Accounting department prior to purchasing the insurance on your behalf. If the purchase price you paid is incorrect or less than the $5.00 minimum when submitting this form, you will be contacted to pay the difference.

There is a $5.00 minimum for purchasing insurance.

If the Purchase Price for Insurance field below shows less than the $5.00 minimum, please use the back button to the previous page and manually update the Total Calculated Cost of Insurance field where this number is pulled from.