Form Plan 3pi - Enrollment Form For International Trips For Girl Scout Councils
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1Plan 3PI
Enrollment Form for International Trips
for Girl Scout Councils
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 international trip.
FROM:
Name of Council _______________________________
Address _____________________________________
City __________________ State ______ ZIP ________
Email ________________________________________
Telephone ____________________________________
Fax __________________________________________
Council approval is required – forms without the appropriate Council signature cannot be processed; group 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 trip (except
statutory employees covered under workers’ compensation).
Trip Schedule
(1)
(2)
(3)
(4)
(5)
Name and Location of Trip
Beginning
Ending
Number of
Number of
Number
Premium
Total
Date
Date
Participants
Days
Participant
Each Day
(3 x 4)
Days (1 x 2)
@ $ 1.17
2/5/XX
2/9/XX
25
5
125
$ 1.17
$ 146.25
SAMPLE: COUNTRY
1.17
1.
N/A
N/A
TOTAL
1.17
ATTENTION TROOP LEADER:
Please attach the trip roster to this enrollment form. (See format on Instruction Sheet.)
Important Note to Leaders: Please prepare and bring a list of emergency parental, guardian or other personal
contacts and their telephone numbers for all participants with you during the trip.
Check made payable to UNITED OF OMAHA LIFE INSURANCE COMPANY for the TOTAL PREMIUM shown above is enclosed.
MINIMUM PREMIUM is $5.00.
✗
Council Signature
_______________________________________
Title ______________________________ Date _______________
M21717_0212
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