Supplemental Insurance Form

All registered member of Girl Scouts of the USA are automatically covered under the Basic Activity Accident Insurance (Plan 1) as well as non-members who are attending a Girl Scout event. The Basic Plan covers registered members for any approved, supervised Girl Scout activity lasting two consecutive nights or less (three nights when one of the nights is a federal holiday).

Additional Supplemental Insurance is required for any Girl Scouts activity that lasts longer than three days and two nights (three nights when one of the nights is a federal holiday).

Before completing this application ensure each participant is the appropriate age to participate in the program. You cannot insure non-participants. (For instance, a 4-year old tag-a-long at an archery event cannot be insured since the child is not old enough to participate in archery.)
Before completing this application, refer to Volunteer Essentials and review Safety Activity Checkpoints or specific emergency procedures and first aid safety guidelines for each activity. Be sure to follow all standards that apply to your trip/activities.
Submit this form and your payment at least 2 weeks prior to the event.
Payment for supplemental insurance must be done via check. Send a check payable to Mutual of Omaha to:

Girl Scouts, Hornets' Nest Council
Attn: Supplemental Insurance
7007 Idlewild Road
Charlotte, NC 28212

See the chart below to calculate the amount. There is a minimum charge of $5.
Contact the GSHNC Customer Care team at 704-731-6500 if you have questions about supplemental insurance.

Troop Leader Name*

First NameLast Name

Troop Leader Email*

Troop Leader Phone Number*

Area CodePhone Number

Troop Leader Address*

Street Address

Street Address 2

CityState

Zip Code

Troop Number*

Service Unit*

Destination*

Destination Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mileage (one way)*

Departure Date*

Date

Departure Time*

:HourMinutesAM/PM Option

Return Date*

Date

Return Time*

:HourMinutesAM/PM Option

Number of Attendees Purchasing Insurance for*

	Registered	Not Registered
Girls
Women
Men
Tagalongs

** Note: if you are purchasing supplemental insurance for an event type in the number of people that you need to purchase insurance for this includes registered members and non-members.

If you are purchasing supplemental insurance for a trip, you should be purchasing insurance for anyone attending the trip (this is only necessary for trips longer than 2 nights).

Total Number of Attendees

Days Calc

Total Number of Days of Trip (including departure and return date)

Type of Insurance Plan:

Plan 3P - Accident and Sickness (Mutual of Omaha as primary insurance)Plan 3PI - International Accident and Sickness

For more information about each plan and coverages for each,
visit the Mutual of Omaha website.

Plan 3P Selected

Plan 3PI Selected

Total Cost 3P

Total Cost 3PI

Because you have selected the 3PI International Coverage, please list the name and age of each participant on your trip.

This form and payment are due 2 weeks before your event or trip. The minimum charge is $5, so you must write a check for $5 if your total is less than $5. Checks must be payable to Mutual of Omaha and mailed or dropped off at the GSHNC Service Center.*

I understand the terms above and will submit a check for at least $5 to GSHNC at least 2 weeks before my event or trip.

I agree that by submitting this form that I have read the Volunteer Essentials manual as well as the Safety Activity Checkpoints that pertain to this trip and have followed the prescribed safety standards in developing this trip. I understand that this trip may not be approved if all trip planning procedures and safety standards have not been met.*

Supplemental Insurance Form

Contact Information