Indiana Conference Pathfinder Yearly Insurance Form

Indiana Conference Pathfinder 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 $4.00 per pathfinder or adult leader.
Church sponsoring this club? *
Director's Name *

First Name Last Name
Director's E-mail *
you will receive an email of this submission

Where are your Pathfinder Club meetings located? *

Director's Mobile Number *

- Area Code Phone Number
Choose your Pastor
Pastor Not listed? *

First Name Last Name
Church Pastor's Email
If you would like to receive a copy of this form.
Pastor's Initials *
Church Treasurer's Email *
If you would like to receive a copy of this form.
Treasurer's Initials *
Please list ALL Volunteers participating in your club. They MUST be listed. *
Total Volunteers *
Please list ALL Pathfinders participating in your club. *
Total Pathfinders *
Total you owe for Insurance Premium? This form will automatically calculate for you.
How are you planning on paying your clubs insurance fees? Mailed to: P.O. Box 5000, Westfield, IN 46074 or use Credit Card *

PayPal (use the PayPal option below) Church Check (please indicate Check number below)
PayPal Payment Option. ONLY use this if you are planning on paying with credit card.

USD Pathfinder Insurance Fees
Date you submitting this form *
Should be Empty: