Activity Insurance Purchase Form

Activity Insurance Purchase Form

For Girl Scouts of Michigan Shore to Shore Troops/Service Units Only
This form is for Girl Scouts of Michigan Shore to Shore (GSMISTS) troops or service units ONLY. If your troop does not belong to Girl Scouts of Michigan Shore to Shore please contact your council directly to find out their process to purchase additional activity insurance.*

I Understand
To purchase additional activity insurance, complete and submit this form with the appropriate fee at least 4 weeks before the activity/trip date.

Notice: There is a $5.00 minimum enrollment fee, $5.00 must be paid even if amount due is less than $5.00. You can submit information (Activity/Trip Name, Name & Address of Activity Location, Dates) for multiple activity insurance purchases to meet the $5.00 minimum enrollment.
First and Last Name*

First NameLast Name
Troop Number*
Service Unit Number*
Day Phone Number*

Area CodePhone Number
Evening Phone Number*

Area CodePhone Number
Contact Email*
example@example.com
Activity/Trip Information

There is a $5.00 minimum enrollment fee, $5.00 must be paid even if amount due is less than $5.00. You can submit information (Activity/Trip Name, Name & Address of Activity Location, Dates) for multiple activity insurance purchases to meet the $5.00 minimum enrollment.
Name of Activity/Trip*
Activity/Trip Information*
List Dates of all Activities/Trips (mm,dd,yyyy)*
Example: 6/8/2020-6/10/2020
Coverages Offered for Purchase

Choose the plan that is best for your activity/trip

Plan 3P: Primary accident and sickness coverage for troop travel for trips and activities ($0.70 per person, per day). This is a great option for longer trips.

Plan 3PI: Accident and sickness coverage for participants in international trips ($1.17 per person, per day).

Example Table

Use this table to help you fill out the table below

Plan	Number of Participants	Number of Days	Number of Participants x number of days	Premium each day	TOTAL DUE
example	15	2	30	.7	21.00
3P				.70
3PE				1.17

Complete the Table Below to Calculate your Cost
- Use the table above to help you calculate your fee.
- The total due will auto-populate using the permium each day highlighted in yellow from the chart above.
- There is a $5.00 minimum enrollment fee, $5.00 must be paid even if amount due is less than $5.00. You can submit information (Activity/Trip Name, Name & Address of Activity Location, Dates) for multiple activity insurance purchases to meet the $5.00 minimum enrollment.
- Fill out the table for EACH of the activities/trips.

Insurance Plan Calculation Table*

	Number of Participants	Number of Days	Number of Participants x Number of Days	Total Due
Plan 3P
Plan 3P
Plan 3PI
Plan 3PI

Payment
Enter the total amount due from the chart above. If you did NOT reach the $5.00 minimum please enter $5.00 in the, Enter Total Amount Due field below.
Enter Total Amount Due*

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USDActivity Insurance Purchase Form
Signature*

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Enter Today's Date*

MonthDayYear
Date
You will be redirected to PayPal for payment. You do not need a PayPal account in order to submit payment.
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Activity Insurance Purchase Form

Activity/Trip Information

Coverages Offered for Purchase

Payment