Plan 3e - Enrollment Form For Girl Scout Councils
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1Plan 3E
Enrollment Form
for Girl Scout Councils
Underwritten by
U nited of Omaha Life
Insurance Company
1. Submit the completed enrollment form through the Girl Scout Council for approval.
2. Following Council approval, the Council will send the completed enrollment form and premium (made payable to United of Omaha
Life Insurance Company) directly to: Mutual of Omaha, Special Risk Services, P.O. Box 31716, Omaha, NE 68131. Enrollment
form and premium must be received by Mutual of Omaha prior to 12:01 a.m. of the first day of the Girl Scout event.
FROM:
(Please complete the address portion
Name of
Council
______________________________________________
in full. This will be used to return
Address
______________________________________________
the Council’s verification copy.)
City
_______________________ State ______ ZIP ________
Council approval is required — forms without the appropriate Council signature cannot be processed; troop leaders should not
submit enrollments directly to Mutual of Omaha.
■ ■ ■
Council Code No.
Leader name or name of person submitting this form _____________________________________________
Please provide Accident and Sickness Insurance to cover all enrolled participants in the following approved, supervised Girl Scout activities
(except statutory employees covered under workers’ compensation):
Schedule of Each Event
(1)
(2)
(3)
(4)
(5)
Name and Location of Event
Beginning
Ending
Number of
Number of
Number
Premium
Total
Date
Date
Participants
Days
Participant
Each Day
(3 x 4)
Days (1 x 2)
@ 29¢
SAMPLE: CAMPING
2/5/XX
2/9/XX
25
5
125
$ .29
$ 36.25
1.
.29
.29
2.
.29
3.
.29
4.
.29
5.
N/A
N/A
.29
TOTAL
Check made payable to UNITED OF OMAHA LIFE INSURANCE COMPANY for the TOTAL PREMIUM shown above is enclosed.
MINIMUM PREMIUM is $5.00, except that several enrollment forms included in one submission may be combined to meet the minimum.
✗
Council Signature
_______________________________________ Title ______________________________ Date _______________
FOR HOME OFFICE USE ONLY
Verification of Coverage to Council SGS21
✗
✗
Approved as Submitted
_________________________ /___ / ___ Approved with Change Marked
__________________ /___ / ___
Signature
Date
Signature
Date
M19060_0507
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