Fillable Additional Activity Insurance Request Form (Girl Scouts of Greater Los Angeles)

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Additional Activity Insurance Request Form (Girl Scouts of Greater Los Angeles)

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Girl Scouts of Greater Los Angeles 1150 S. Olive Street., Ste 600 Los Angeles, CA 90017 Phone (213) 213-0123 www.girlscoutsla.org
THINGS TO REMEMBER
➢ When counting number of days, count each day not a 24-hour period.
(Ex: A campout from Friday 3:00 p.m. - Sunday 10:00 a.m. would be 3 days.)
➢ There is a ($5.00) minimum purchase.
➢ Payments are processed using bank account information provided and will appear from Mutual of Omaha.
➢ Enrollment request must be submitted no later than 2 weeks prior to the event/departure date, or 4 weeks for
extended/international trips.
➢ You only need to purchase one type of additional insurance per event. Contact Customer Care at 213-213-0123 for assistance.
FOR YOUR CONVENIENCE, BELOW ARE THE ADDRESSES FOR EACH GSGLA SERVICE CENTER.
Arcadia Service Center
101 E. Wheeler Ave.
Arcadia, CA 91006
GSGLA Headquarters
1150 S. Olive Street, Ste. 600
Los Angeles, CA 90015
Inglewood Service Center
423 N. La Brea Ave.
Inglewood, CA 90302
Long Beach Service Center
4040 N. Bellflower Blvd.
Long Beach, CA 90808
Palmdale Service Center
41307 12th Street West, #105
Palmdale, CA 93551
Santa Clarita Service Center
18316 Soledad Canyon Rd
Santa Clarita, CA 91387
Upland Service Center
313 E. Foothill Blvd.
Upland, CA 91786
ACTIVITY ACCIDENT INSURANCE
REQUEST FORM
DO YOU NEED ACTIVITY ACCIDENT INSURANCE?
1) Will any non-Girl Scouts be participating in your event/trip?
YES -- Please fill out enrollment for Plan 2 below & submit at least 2 weeks prior to event/trip
NO -- Continue with question 2.
2) Is your trip/event more than 2 nights (3 if it includes a Federal Holiday)?
YES -- Please fill out enrollment for Plan 3E or 3P below, for ALL participants, & submit at least 4 weeks prior to trip.
NO -- Continue with question 3.
3) Is your trip to an international location?
YES -- Please fill out enrollment for Plan 3PI below, for ALL participants, & submit at least 4 weeks prior to trip
NO
IF YOU ANSWERED YES TO QUESTION 1, 2, OR 3, PLEASE COMPLETE AN ENROLLMENT FORM BELOW
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Girl Scouts of Greater Los Angeles 1150 S. Olive Street., Ste 600 Los Angeles, CA 90017 Phone (213) 213-0123 www.girlscoutsla.org
Include notes or attach additional documentation here if needed:
Plan(s) Subtotal
Plan(s) Total:
ACTIVITY ACCIDENT INSURANCE
REQUEST FORM
EVENT INFORMATION
Event/Trip Name/Description:
Special Event ID # (if applicable):
If this is an event, will 4 or more troops be participating in it? □ YES □ NO If YES, how many?
Event/Trip Location:
Event/Trip Date(s):
FROM
TO
Adult in Charge: Email:
Day Phone: Evening Phone:
Evening Phone
Troop/Service Unit Requesting Insurance:
(1)
(2)
(3)
(4)
(5)
(6)
Plan Type
# Girl
Scouts
# Non-Girl
Scouts
Total #
Participants
= Col 1 + Col 2
Total # of
Days
Participant
Days
= Col 3 x Col 4
Premium
each Day
Total
=Col 5 x Col 6
2 (covers
accidents only)
N/A
11¢
3E (covers
accidents &
illness;
coordinates with
any family health
plan
29¢
3P (covers
accidents &
illness; is primary
coverage)
70¢
3PI (covers
accidents, illness,
and travel
assistance
services)
$1.17
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Additional Activity Insurance Request Form (Girl Scouts of Greater Los Angeles)

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Completed 25 July 2021

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