Girl Scouts of NE Kansas & NW Missouri
8383 Blue Parkway, KC MO 64133
(816) 358-8750 FAX (816) 358-5714
INSURANCE PURCHASE FORM: Troop/Service Unit Meetings
Additional insurance must be purchased for all non-registered person(s) participating in GS events. To purchase additional
insurance, complete and submit this form with the appropriate fee at least 2 weeks before the event date.
: ____________________________________________________ Troop
:_______________
: ______________
Name
#
SU#
:_______________________________________________________________________________________
Street Address
: _________________________________________________________
:_________
:_______________
City
State
Zip Code
: (
) ___________________ Tel
: (
)_________________
:___________________________________
Tel. Day
Eve
E-mail
This form is to be used only for multiple one day events, i.e. Girl Scout meetings, Service Unit meetings, etc. Please note overnights
can be included as one event by including both dates in the Date of Event column.
PLEASE COMPLETE THE CHART BELOW (Limited to 15 events ONLY)
Event
Location & Address
Date of Event
# of
Premium
TOTAL DUE
Participants
each day
Example SUV Meeting
XYZ School
01/18/12
15
@ .11
$1.65
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
.11
$ 0.00
Plan 2:
Accident coverage for participants = non-members participating in an approved and supervised Girl Scout activity. ($0.11 per person per
day)
Payment:
•
Forms submitted at least 4 weeks prior to the event/trip should include payment for the exact amount. Payment can be
made in the form of a check or debit/credit card. Checks should be made out to Girl Scouts.
•
Forms submitted less than 4 weeks before the event/trip must meet a $5 minimum purchase. All insurance must be
purchased 2 weeks in advance of the event. Payment can be made in the form of a check made out to Girl Scouts or by
debit/credit card. If the total insurance needed is less than $5, you must pay $5.
Check #: ____________ Amount Due:$______________
____ Visa ____ Mastercard ____ Discover
Credit Card #: _________________________________________ Exp#_____________
Signature: __________________________________________________________________________ Date:____________________
11/15
1
