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Girl Scouts - Additional Insurance for Girl Scouts of Greater Chicago and Northwest Indiana

Activity insurance is available for Girl Scouts taking extended trips and for nonmembers
who participate in Girl Scout activities. These plans are secondary insurance that a council
may offer to cover participants taking part in any council-approved, supervised Girl Scout activity.
Optional insurance coverage is available for any Girl Scout activity that involves non-Girl Scouts or lasts longer than three days and two nights.

Instructions: Complete all required fields (indicated by a red *).

Following Council approval, the Council will send the completed enrollment form and premium directly to:
Mutual of Omaha Companies, Special Risk Services, P.O.Box 31716, Omaha, NE 68131.

Enrollment form and premium must be received by Mutual of Omaha 7 days, prior to 12:01 a.m. of the first day of the event. Please submit 7 days prior to event.

This insurance is for Council Code: 430

Complete the following contact information for the troop leader or person completing this form.

First Name & Last Name *

Street Address *

City *

State *

Zip Code
Format: 00000 *

Phone Number
Format: 000-000-0000 *

Troop number
Format:12345 *

Email Address *

Which plan are you submitting for? *

Plan 2 - is no longer required by GSUSA.

Plan 3E - Accident and Sickness Insurance: This plan is recommended for trips out of state or for any other trip where sickness could occur, such as extended trips out of town.

Plan 3P - Accident and Sickness Insurance: For groups with one or more participants who do not have a personal family insurance (or where personal insurance may not be honored). Plan 3P acts as primary insurance for participants covered by the plan.

Plan 3PI - Accident and Sickness Insurance for International Trips: For any Girl Scout group planning a trip out of the country. Due to certain pre-trip benefits, this insurance should be purchased in the planning stages of the trip, but after the trip has been approved by the council.