Girl Scouts Of The Commonwealth Of Va Request For Additional Insurance Form
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GIRL SCOUTS OF THE COMMONWEALTH OF VA
Executive at least 2
weeks prior to event.
REQUEST FOR ADDITIONAL INSURANCE
To purchase additional insurance, please submit this form to the council office with a CHECK payable to
GSCC along with your Trip/Activity Form (TAF).
NOTE: Additional insurance is required for activities lasting more than two nights and suggested
for activities that include non-members. (See back of form for additional information.)
PLEASE CHECK TYPE OF EVENT AND CALCULATE TOTAL PREMIUM:
Required Insurance:
_____ Troop activity lasting more than two nights (three nights when one of the nights is an official federal
holiday) --11¢ per day per participant. (Accident only coverage.)
______
x
______
=
______
x
11¢
=
______
# participants
# days
# participant days
premium each day
total premium*
_____ Troop or service unit international activity with coverage for accident and sickness--$1.17 per day
per member or non-member. (Primary coverage, not subject to coordination of benefits.
(Includes emergency travel assistance service. Strongly recommended by United of Omaha.)
______
x
______
=
______
x
$1.17
=
______
# non-members
# days
# participant days
premium each day
total premium*
Optional Insurance:
_____ Troop activity or service unit event with non-member participants -- 11¢ per day per non-member.
(Accident only coverage.)
______
x
______
=
______
x
11¢
=
______
# non-members
# days
# participant days
premium each day
total premium*
_____ Troop or service unit activity with coverage for accident and sickness -- 29¢ per day per member
and non-member. (Coordinates with any family health plan.)
______
x
______
=
______
x
29¢
=
______
# participants
# days
# participant days
premium each day
total premium*
_____ Troop or service unit activity with coverage for accident and sickness--67¢ per day per member
or non-member. (Primary coverage, not subject to coordination of benefits.)
______
x
______
=
______
x
67¢
=
______
# non-members
# days
# participant days
premium each day
total premium*
*The minimum cost for all premiums is $5.00. Coverage begins at the time of departure,
therefore be sure to include beginning and ending travel days in your calculations.
Leader’s Name: _________________________________ Daytime telephone:___________________
Address: __________________________________________________________________________
Street
City
State
Zip Code
Troop Number: ____________
Service Unit Name :______________________________________
Date Activity Begins: _______________________
Date Activity Ends:_________________________
Destination(s): _____________________________________________________________________
Number of Participants: __________________ (Include girls, adults and non-members)
Description of Activity: ________________________________________________________________
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