Request for Additional Insurance

Request for Additional Insurance
Troop or SU# / Group Name*
Grade Levels (check all that apply)*

DaisyBrownieJuniorCadetteSeniorAmbassador
Requesting Volunteer's Contact Info
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Event Name
Event Location (site/city/state)*
Beginning Date*
Ending Date*
Beginning Date*

MonthDayYear
Date
Ending Date*

MonthDayYear
Date
Emergency Contact Person*

First NameLast Name
Emergency Contact Person Phone*

Area CodePhone Number
Number of Registered Girl Members*
Number of Registered Adult Members*
Number of Non-Registered Participants*
Type of Insurance requested (Select 1) See chart below for explanations of policies*

Plan 3EPlan 3PPlan 3PIUnsure, please advise

Plan Name	Coverage Type	Coverage	Cost/Person as of June 2017*	When to Use
Plan 1	Basic	Accident Only	Included with Annual Membership	For all member and nonmember participants of Girl Scout sponsored/supervised events and travel within the U.S. territory.
Plan 3P	Primary	Accident & Sickness	$0.70 per day	For events lasting longer than those covered by plan 1 when use of the family health plan is not possible.
Plan 3E	Excess	Accident & Sickness	$.29 per day	For events lasting longer than those covered by Plan 1. Coordinates with any family health plan.
Plan 3PI	Primary	Accident & Sickness & Travel Assist	$1.17 per day	Events outside USA

*$5 minimum