Indiana Conference Pathfinder Yearly Insurance Form

Indiana Conference Adventurer 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.

Your cost is $5.00 per pathfinder or adult leader.
Church sponsoring this club?*
Church not listed? enter here
Director's Name*

First NameLast Name
Director's E-mail*
you will receive an email of this submission
Where are your 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.
Church Treasurer's Email
If you would like to receive a copy of this form.
Please list ALL Volunteers participating in your club. They MUST be listed.*
Total Volunteers*
Please list ALL Adventurers participating in your club. *
Total Adventurers*
Total you owe for Insurance Premium? This form will automatically calculate for you.
There are two ways to pay clubs insurance fees

1. Pay with Credit card, Google pay, Cash app or Apple pay

2. Mailed Church Check to: P.O. Box 5000, Westfield, IN 46074 (Check must be RECEIVED by the deadline)
Ways to pay*

Church Check (please indicate on memo portion of check it's for insurance)Credit Card/Cash App/Google Pay/Apple pay
Date you submitting this form*

Club Insurance Fees

USDDescription

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Should be Empty:

Indiana Conference Adventurer Yearly Insurance Form

Payment Methods