Girl Scouts Of Ne Kansas & Nw Missouri Insurance Purchase Form
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4Girl Scouts of NE Kansas & NW Missouri
8383 Blue Parkway, KC MO 64133
(816) 358-8750 FAX (816) 358-5714
INSURANCE PURCHASE FORM
Additional insurance must be purchased for all non-registered person(s) attending 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
: ________________________________________________________________________________________
Event Name
: _______________________________________________________________________
Name & Address of Event Location
____________________________________________________________________________________________
Date(s):
COMPLETE THE CHART BELOW FOR THE TYPE(S) OF INSURANCE COVERAGE NEEDED
Plan 2:
Accident coverage for participants in Girl Scout activities or for non-members participating in an approved and supervised Girl Scout
activity. ($0.11 per person per day)
Plan 3E:
Supplemental accident and sickness coverage for troop travel 3 days/2 nights or longer. ($0.29 per person per day)
Plan 3P:
Accident and sickness coverage for troop travel 3 days/2 nights or longer. ($0.70 per person per day)
Plan 3PI:
Accident and sickness coverage for troops participating in international trips. ($1.17 per person per day)
PLAN
Number of
Number of
Number of participants X
Premium each
TOTAL DUE
Participants
Days
Number of days
day
Example
15
2
30
@ .11
$3.30
2
@ .11
0
$ 0.00
3E
@ .29
0
$ 0.00
3P
@ .70
0
$ 0.00
3P-1
@ 1.17
0
$ 0.00
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
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