Girl Scouts Of Connecticut - Mutual Of Omaha Enrollment Form - Plan 2
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1GIRL SCOUTS OF CONNECTICUT
20 Washington Avenue, North Haven, CT 06473
1-800-922-2770
M
O
E
F
– P
2
UTUAL OF
MAHA
NROLLMENT
ORM
LAN
•
Additional Activity Insurance is required when ANY person – girl, sibling, adult or anyone who is not currently registered as a Girl Scout member
will participate in a meeting, or a trip, or other Girl Scout gathering. It is also required for Service Unit events and trips lasting more than two
.
consecutive nights
•
supplemental
Plan 2 is a
insurance for accidents only. It covers travel directly to and from any approved and supervised Girl Scout activity.
•
All requests for additional Activity Insurance must be submitted at least two weeks prior to the activity or event. Forward the enrollment form
along with payment to your Membership Manager for processing.
•
Enrollment forms submitted less than two weeks before an activity or event may jeopardize the purchase of additional Activity Insurance. To
ensure for the safety of all participants, adhere to submission deadlines.
•
Make checks payable to: UNITED OF OMAHA LIFE INSURANCE COMPANY for the TOTAL PREMIUM. Minimum premium is $5.00.
•
If for any reason the event/trip is rescheduled, contact your Membership Manager with the new date within 24 hours of the cancellation. If we
are not contacted within the specific time, the premium is forfeited and a new enrollment form, along with payment, must be re-submitted.
•
For further assistance, contact your Membership Manager or email .
Please Note:
To obtain additional Activity Insurance coverage for
extended trips
, contact your Membership Manager for enrollment and/or submission
instructions.
Contact Information
Name of Person completing form (first, last)
Service Unit/Troop
Address
Home Phone
Cell Phone
Email
Below is a schedule of each event.
(1)
(2)
(3)
(4)
(5)
Number of
Premium
Beginning
Ending
Number of
Number
Total
Name & Location of Event
Participant
Each Day
Date
Date
Participants
of Days
(3) x (4)
Days (1) x( 2)
@ 11 cents
Example: Bowling Event, Scout Lanes,
2/5/xx
2/9/xx
25
5
125
$13.75
$ .11
12 Girl Scout Dr, National Way, GS 12345
$ .11
$0.00
0
$ .11
0
$0.00
$ .11
0
$0.00
$ .11
0
$0.00
$ .11
0
$0.00
TOTAL
N/A
N/A
N/A
N/A
$. 11
0
$0.00
Mutual of Omaha Plan 2 Enrollment forms cannot be sent directly to the insurance company. Those sent directly to Mutual of Omaha will be returned unprocessed
and therefore, delays obtaining additional insurance coverage.
Minimum premium is $5.00. Several enrollment forms included in one submission may be combined to meet the minimum required. Enrollment forms submitted
with less than the required $5.00 will be returned unprocessed.
I verify that all the above information is true and correct to the best of my knowledge and approved as submitted.
Signature
Date
For Office Use only:
Date Received
Date Entered
Date Sent to Mutual of Omaha
Mutual of Omaha Enrollment Form - Plan 2- 8-25-15
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