REQUEST FOR ADDITIONAL INSURANCE

PLAN 1 – BASIC INSURANCE

Coverage is automatically provided to girls and adults who register as Girl Scout members. The basic plan covers every registered Girl Scout and Adult Member for any approved, supervised activity of the Girl Scouts, except activities lasting more than two (2) consecutive nights (a third night is covered if the event is over an official federal holiday). [This plan is secondary insurance coverage.]

PLAN 2 – ACCIDENT INSURANCE ($0.11 person/day)

Same type of coverage as Basic Insurance but designed specifically for: events/activities lasting more than two nights (or more than three nights if over an official federal holiday)/or it covers non girl scout members (non-members are girls 5-17) for any approved, supervised activity of the girl scouts. If covering nonmembers for a program when the exact numbers are not available, use a reasonable estimate to determine the number of nonmember participants. [This plan is secondary insurance coverage.]

PLAN 3E – ACCIDENT & SICKNESS INSURANCE ($0.29 person/day)

Same coverage as Insurance Plan 2, but also includes sickness coverage and is designed for the same type of events as Plan 2. [This plan is secondary insurance coverage.]

PLAN 3P – ACCIDENT & SICKNESS INSURANCE ($0.70 person/day)

Same accident and sickness coverage as Plan 3E, but is not subject to the “non-duplication provision.” Plan 3P is for travel within the United States. The payment of bills—by cash or credit card—by the leader is expected and the leader can be reimbursed quickly. [This plan is primary insurance coverage.]

PLAN 3PI – INTERNATIONAL ACCIDENT & SICKNESS INSURANCE ($1.17 person/day)

REQUIRED FOR INTERNATIONAL TRAVEL Includes essentially the same coverage found in Plan 3P, but with a Travel Assistance Services “safety net” feature added for International travel purposes. Should a medical or other emergency occur while abroad, or if there are concerns before making a trip abroad, the Council or group leader is a free telephone call away from mobilizing AXA Assistance resources to provide their “hands on” assistance as detailed in the Description of Coverage. [Attach a copy of the trip roster to the enrollment form.]

PLEASE SUBMIT TWO TO FOUR WEEKS PRIOR TO DEPARTURE DATE

Select a Plan*

Select

Departure Date*

Return Date*

Total # of Days*

Total # of Participants*

Total AMOUNT DUE*

MINIMUM $5.00 – NO REFUNDS

Troop #*

Leader’s Name*

Phone*

Phone

Leader’s Street Address*

City*

State*

Zip*

Email*

Trip or Event*

Location/Destination*

Routing No.*

Checking Account No.*

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