Extra Insurance Request Form
Registered Girl Scouts (Girls and Adults) are covered by accident activity insurance through Mutual of Omaha Insurance Co (Basic Coverage Plan 1). For all trips longer than two (2) nights, international trips and trips/activities where non-Girl Scouts are in attendance extra insurance must be obtained. Each day of the trip must be covered, including travel days. This from along with payment and an itinerary must be submitted four (4) weeks before the trip/activity 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
*
Pan 2: $0.11 per day per participant accident
Plan 3E: $0.29 per day per participant accident and sickness, supplemental
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:
*
0.11
0.29
0.70
1.17
Final Cost ($5 minimum required by Mutual of Omaha)
Calculation
Payment Amount
prev
next
( X )
USD
Mutual of Omaha requires a minimum payment of $5
Submit
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