Indiana Conference Pathfinder Yearly Insurance Form

Indiana Conference Pathfinder Yearly Insurance Form

DEADLINE: OCTOBER 1
The Indiana Conference purchases liability and medical coverage for our pathfinder clubs. The medical coverage is for $5000 primary, if the activity is on our premises or $5000 excess, if an accident occurs during a sponsored activity off premises.

NEW PRICE!
Your cost is $5.00 per pathfinder or adult leader.
Church sponsoring this club?*
Director's Name*

First NameLast Name
Director's E-mail*
you will receive an email of this submission
Where are your Pathfinder Club meetings located?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Director's Mobile Number*

Area CodePhone Number
Choose your Pastor*
Pastor Not listed?

First NameLast Name
Church Pastor's Email
If you would like to receive a copy of this form.
Treasurer's name

First NameLast Name
Church Treasurer's Email
If you would like them to receive a copy of this form
Please list ALL Pathfinders participating in your club. *
Total Pathfinders*
Please list ALL volunteers participating in your club. *
Total Volunteers*
Please list ALL Volunteers participating in your club. They MUST be listed.*
Total you owe for Insurance Premium? This form will automatically calculate for you.
How are you planning on paying your clubs insurance fees?*

Credit Card/Google Pay/Apple Pay/Cash AppChurch Check (please indicate in memo this check is for club insurance)
This section for Credit Card, etc payments.

If there are numbers in the cell below, erase before submitting

Club Insurance Fees

USDPathfinder Annual Fee

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Date you submitting this form*
Name of your church if not listed above
Should be Empty:

Indiana Conference Pathfinder Yearly Insurance Form

This section for Credit Card, etc payments.

Payment Methods