Certificate of Insurance Request Form

Additional Insurance Request Form

Insurance for Extended Travel
Girl Scouts' Basic Insurance plan covers invited participants who are attending and participating in a Girl Scout activity. Some Girl Scout activities require additional insurance.

When Girl Scout groups participate in extended travel, Girl Scouts of NYPENN Pathways requires additional insurance to cover participants in the event of sickness/illness while traveling. The additional insurance is priced to be affordable and is required for 100% of participants for the entirety of the event.
- For approved travel over 3 nights that takes place more than 3 hours from home or in another state, groups must purchase the 3P Insurance plan ($.70pp/day) that includes illness/sickness primary insurance in addition to supplemental accident insurance.
- For approved international travel (including Canada), groups must purchase the 3PI plan ($1.13pp/day) that includes international illness/sickness primary insurance in addition to supplemental accident insurance.
Please submit requests at least 3 weeks prior to the travel date and after the travel is approved
Requester Information:
Service Unit #:*
Troop #:*
Requester's Name:*
Email Address:*
example@example.com
Type of Insurance Request:*

Insurance for Extended Travel (3-days or more; 3+ hours from home or out-of-state)Insurance for International Travel (including Canada)
Event End Date*

MonthDayYear
Name of Event:*
Event Location:*
Number to Insure:*
Extended Travel Insurance Information:

Trip must be approved prior to purchasing additional insurance for an extended trip.
Is this an international trip:*

YesNo
Trip Start Date*

MonthDayYear
Trip End Date*

MonthDayYear
Trip Details:*
Total Number of Participants:*
International Trip Details:*
Please allow 3 business days to be processed. If you have any further questions, please contact:

info@gsnypenn.org or call us at 1.315.221.3552 or 1.800.943.4414
Should be Empty:

Additional Insurance Request Form