Form M18979 - Girl Scouts Of The U.s.a. Claim Form Page 2
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1
2GIRL SCOUT LEADER STATEMENT
■
■
■
■
0
Daisy
3
Cadette
6
Nonmember Child
9
Seasonal Staff
■
■
■
■
Level:
1
Brownie
4
Senior
7
Nonmember Adult
51
Ambassador
Troop Number __________________
■
■
■
2
Junior
5
Adult Member
8
Staff
Name of Council
Council No.
Phone Number
(
)
-
Council’s address
Number and Street
City
State
ZIP Code
Date and place
Date and location
Nature and details of injury or sickness
of accident
or sickness
Type of activity (check below):
■
■
■
■
■
1.
Autos/Vehicles
2.
Slips/Falls on/at/over/from
3.
Using Tools
4.
Aquatics (in/on water)
6.
Skating
■
■
■
Saw
Swimming/Diving
Roller
■
■
Driver
Equipment/Furniture
Activity
■
■
■
Knife
Boating/Canoeing
Ice
■
■
information
Passenger
Animals
■
■
Stove
Water Skiing
■
7.
Illness/Sickness
■
■
■
Pedestrian
Other (carpet, log,
Kiln
■
5.
Poisonous Plants/Insects
■
8.
Other Accident
■
stairs, etc.)
Other
(poison ivy/bee stings)
■
■
Was this an overnight event?
Yes
No If “Yes,” number of nights ____________
Overnight
Name of event:
events
Indicate dates of attendance from
to
We hereby certify that the insured person is a currently registered Girl Scout or that the required premium for insurance coverage has been paid for
this person and that the claimant was participating in an authorized Girl Scout activity as described above.
Troop
___________________________________________________________________________________________________________________________
validation or
Activity Representative’s Signature/Troop Leader’s Signature
Date
authorized
activity
___________________________________________________________________________________________________________________________
representa-
Street Address
City
State
ZIP Code
tive’s
validation
■
■
Did injury occur during course of employment?
Yes
No
Claims covered by the Council’s workers’ compensation policy should not be submitted to United of Omaha.
I certify that this injury or sickness occurred as described and that the activity was sponsored and supervised by the Girl Scouts.
COUNCIL
USE ONLY
Council Official’s Signature
Date
Authorization for Release of Information
I authorize the Mutual of Omaha Insurance Company and/or its affiliated companies to disclose my or my children’s personal
information to Girl Scouts U.S.A. for purposes of claim confirmation.
The personal information may include such items as claim and medical information, including diagnosis, mental and physical
condition, prescription drug records, and other related claim information.
I understand that I may refuse to sign this authorization. My refusal to sign will not affect my enrollment, my eligibility for benefits
or my ability to obtain payment, but may delay the processing of my claim.
If the person or entity to whom information is disclosed is not a health care provider or health plan subject to federal privacy
regulations, the information may be redisclosed without the protection of the federal privacy regulations.
Unless revoked earlier, this authorization will remain in effect for 24 months from the date I sign it. I understand that I may revoke
this authorization at any time, by written notice to: Mutual of Omaha Insurance Company, ATTN: Special Risk Claims, Mutual of
Omaha Plaza, Omaha, NE 68175.
I understand that I am entitled to receive a copy of the signed authorization.
_______________________________________________
______________________________
Signature
Date
_______________________________________________
Relationship to Insured
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