Insurance Information for Troop Travel & High Adventure Girl Scouts of Citrus Council 341 N. Mills Ave. Orlando, FL 32803 (407) 896-4475 www.citrus-gs.org
Important Information about Ordering Insurance Optional insurance plans MUST be purchased 4 weeks in advance of the activity and 8 weeks for outof-state or out-of-country travel. If you make a late request to the council, you will be asked to prepare the enrollment form and forward it with your check to Marie Snead at msnead@citrus-gs.org in time for verification, signature and mailing. Only the Troop Leader or other registered adult in charge may order insurance. Requests for insurance MAY NOT be transmitted directly to Mutual of Omaha. The appropriate form must be completed and forwarded (with payment by check, money order or credit card) to the Council Service Center for approval (see Steps for Purchasing Insurance). There is a $5 minimum charge for all insurance requests. Additional Event/Travel Insurance is secondary insurance. The insured party s family insurance plan is primary. Mutual of Omaha pays the first $130 of an approved claim, and will continue (after the family insurance plan has reached its coverage limit) up to a total of $15,000 for each claim. Steps for Purchasing Additional Event/Trip Insurance: 1. Determine which plan(s) you need for your event, see the Girl Scout Insurance Plan Comparison Chart. Please call or email Marie Snead with questions at (407) 228-1616 or msnead@citrus-gs.org. 2. Print the most current Enrollment Form. A. Select the desired enrollment plan (Plan 2, Plan 3E, Plan 3P, and Plan 3PI ). B. Print the form. 3. Complete the Enrollment Form(type or print legibly) Enter the mailing address at top of form, which is: A. Enter YOUR name, address, telephone number and e-mail address as person preparing form. B. Include the name of the event and the city in the Name/Location of Event column. C. Total ALL columns (use dollar signs on all money amounts). D. Do NOT date enrollment forms (council will sign and date after verification). E. Attach your payment for total payment to the form. Make checks or money orders payable to Girl Scouts of Citrus Council. PLEASE DO NOT SEND CASH. Please Note: The minimum purchase for insurance is $5.00. Therefore, if the total cost of your insurance is under $5.00, a check for no less than $5.00 must be included.
4. Forward completed Enrollment Form WITH your check, money order or credit card to the council: Girl Scouts of Citrus Council 341 N Mills Ave Orlando, FL 32803 Send the form as soon as possible before the first day of the event to allow time for verification, signature and mailing. The form and payment must be in the council office at least 4 to 8 weeks in advance of the event or trip. Please Note: If a form is incomplete or inaccurate, or if a check is in the wrong amount or under $5.00, they will be returned to you and not processed. For more information More information about insurance is available by calling Marie Snead at (407) 228-1616 or emailing msnead@citrusgs.org Instructions for Submitting Insurance Claims (All Plans) As with ordering insurance, you may NOT submit the claim directly to the insurance company. Steps for Filing a Claim: 1. Print out the claim form. Go to the Mutual of Omaha website: www.mutualofomaha.com/gsusa a. Click on "How to file a Claim and Claim Forms" b. Scroll down the page and click on Claim Forms (Print out all 3 pages and staple together) 2. Complete the form in full and sign wherever appropriate. Do not complete the very bottom section (for council use only) 3. Send the claim form to the Council Service Center, attention: Marie Snead, for validation, along with any bills received at the time. Girl Scouts of Citrus Council 341 N Mills Ave Orlando, FL 32803 Attention: Marie Snead 4. Council will complete the council section, sign and mail to the insurance company. 5. Send any subsequent bills related to this claim to Marie Snead at the council office. If you prefer to receive hard copies of claim forms, please contact Marie Snead (407) 228-1616 or msnead@citrusgs.org.
Girl Scout Insurance Plan Comparison Chart PLAN 1 Accident Insurance Automatic coverage for registered members for a Girl Scout event which does not exceed a total of 3 days/2 nights. You do not need to order this insurance, since it is automatically applied to all Girl Scout members, unless there are high adventure activities involved. PLAN 2 Accident Insurance To cover participants who are NOT registered Girl Scouts and/or Girl Scouts participating in an event lasting MORE than 3 days, 2 nights. Example: If your troop is planning a trip for 5 days and 4 nights, you will need to purchase insurance for all of the registered members for the full 5 days because the trip is longer than 3 days, 2 nights. PLAN 3E Accident and Sickness Insurance This plan is recommended for trips out of state or for any other trip where sickness could occur, such as extended trips out of town. PLAN 3P Accident and Sickness Insurance For groups with one or more participants who do not have personal family insurance (or where personal insurance may not be honored). Plan 3P acts as primary insurance for participants covered by the plan. PLAN 3PI Accident and Sickness Insurance for International Trips For any Girl Scout group planning a trip out of the country. Due to certain pre-trip benefits, this insurance should be purchased in the planning stages of the trip, but after the trip has been approved by the council, Call the council office to obtain detailed information on how to purchase this plan. INTERNATIONAL INBOUND Accident and Sickness Insurance for Girl Guides/Girl Scouts Visiting the USA Can be purchased by groups who are hosting Girl Guides/Girl Scouts visiting the USA. This insurance covers the visiting Girl Guides/Girl Scouts.
Insurance Forms Plan 2, Plan 3E, Plan 3P, and Plan 3PI
Plan 2 Enrollment Form for Girl Scouts 1. Submit the completed enrollment form through the Girl Scout Council for approval. Please send your payment, made out to GSCC. 2. Following Council approval of all paperwork, the information on enrollment form will be used to purchase the required premium online. You will be notified via e-mail of confirmation of purchase. 3. If this to be used for international travel, a list of participants with their birthdates is required. Council approval is required forms without the appropriate Council signature cannot be processed; troop leaders should not submit enrollments or payments directly to Mutual of Omaha Companies. (Please complete the address portion in full. This will be used to return the Council s verification copy.) Name (Leader or person submitting this form) Troop # Service Unit Street City State Zip Phone # E-mail Please provide Accident and Sickness Insurance to cover all enrolled participants in the following approved, supervised Girl Scout activities (except statutory employees covered under workers compensation.) Name & Location of Event Beginning Date Ending Date Number of Participants Number of Days Number Participant Days (1x2) Premium Each Day @ $.11 Total (3x4) Sample: Camping 2/5/XX 2/9/XX 25 5 125 $.11 $13.75 MINIMUM PREMIUM is $5.00 several events can be included in one submission to be combined to meet the minimum. Method of payment: Check Money Order VISA MASTERCARD DISCOVER If paying by credit card, information below MUST BE INCLUDED: ACCOUNT # EXP. DATE / Sec. Code - - (fill in all digits shown on your credit card) M M Y Y Name as it appears on Credit Card: (Print) Signature (required on credit card orders) COUNCIL USE ONLY: Budget Code: - - - - - Insurance Plan 2 July 2015
Plan 3E Enrollment Form for Girl Scouts 1. Submit the completed enrollment form through the Girl Scout Council for approval. Please send your payment, made out to GSCC. 2. Following Council approval of all paperwork, the information on enrollment form will be used to purchase the required premium online. You will be notified via e-mail of confirmation of purchase. 3. If this to be used for international travel, a list of participants with their birthdates is required. Council approval is required forms without the appropriate Council signature cannot be processed; troop leaders should not submit enrollments or payments directly to Mutual of Omaha Companies. (Please complete the address portion in full. This will be used to return the Council s verification copy.) Name (Leader or person submitting this form) Troop # Service Unit Street City State Zip Phone # E-mail Please provide Accident and Sickness Insurance to cover all enrolled participants in the following approved, supervised Girl Scout activities (except statutory employees covered under workers compensation.) Schedule of Each Event: Name and Location of Event Beginning Date Ending Date Number of Participants Number of Days Number Participant Days (1x2) Premium Each Day @ $.29 Total (3x4) Sample: Camping 2/5/XX 2/9/XX 25 5 125 $.29 $36.25 MINIMUM PREMIUM is $5.00 several events can be included in one submission to be combined to meet the minimum. Method of payment: Check Money Order VISA MASTERCARD DISCOVER If paying by credit card, information below MUST BE INCLUDED: ACCOUNT # EXP. DATE / Sec. Code - - (fill in all digits shown on your credit card) M M Y Y Name as it appears on Credit Card: (Print) Signature (required on credit card orders) COUNCIL USE ONLY: Budget Code: - - - - - Insurance Plan 3E July 2015
Plan 3P Enrollment Form for Girl Scouts 1. Submit the completed enrollment form through the Girl Scout Council for approval. Please send your payment, made out to GSCC. 2. Following Council approval of all paperwork, the information on enrollment form will be used to purchase the required premium online. You will be notified via e-mail of confirmation of purchase. 3. If this to be used for international travel, a list of participants with their birthdates is required. Council approval is required forms without the appropriate Council signature cannot be processed; troop leaders should not submit enrollments or payments directly to Mutual of Omaha Companies. (Please complete the address portion in full. This will be used to return the Council s verification copy.) Name (Leader or person submitting this form) Troop # Service Unit Street City State Zip Phone # E-mail Please provide Accident and Sickness Insurance to cover all enrolled participants in the following approved, supervised Girl Scout activities (except statutory employees covered under workers compensation.) Schedule of Each Event: Name and Location of Event Beginning Date Ending Date Number of Participants Number of Days Number Participant Days (1x2) Premium Each Day @ $.70 Total (3x4) Sample: Camping 2/5/XX 2/9/XX 25 5 125 $.70 $87.50 MINIMUM PREMIUM is $5.00 several events can be included in one submission to be combined to meet the minimum. Method of payment: Check Money Order VISA MASTERCARD DISCOVER If paying by credit card, information below MUST BE INCLUDED: ACCOUNT # EXP. DATE / Sec. Code - - (fill in all digits shown on your credit card) M M Y Y Name as it appears on Credit Card: (Print) Signature (required on credit card orders) COUNCIL USE ONLY: Budget Code: - - - - - Insurance Plan 3E July 2015
Plan 3PI Enrollment Form for Girl Scouts 1. Submit the completed enrollment form through the Girl Scout Council for approval. Please send your payment, made out to GSCC. 2. Following Council approval of all paperwork, the information on enrollment form will be used to purchase the required premium online. You will be notified via e-mail of confirmation of purchase. 3. If this to be used for international travel, a list of participants with their birthdates is required. Council approval is required forms without the appropriate Council signature cannot be processed; troop leaders should not submit enrollments or payments directly to Mutual of Omaha Companies. (Please complete the address portion in full. This will be used to return the Council s verification copy.) Name (Leader or person submitting this form) Troop # Service Unit Street City State Zip Phone # E-mail Please provide Accident and Sickness Insurance to cover all enrolled participants in the following approved, supervised Girl Scout activities (except statutory employees covered under workers compensation.) Schedule of Each Event: Name and Location of Event Beginning Date Ending Date Number of Participants Number of Days Number Participant Days (1x2) Premium Each Day @ $1.17 Total (3x4) Sample: Camping 2/5/XX 2/9/XX 25 5 125 $1.17 $146.25 MINIMUM PREMIUM is $5.00 several events can be included in one submission to be combined to meet the minimum. Method of payment: Check Money Order VISA MASTERCARD DISCOVER If paying by credit card, information below MUST BE INCLUDED: ACCOUNT # EXP. DATE / Sec. Code - - (fill in all digits shown on your credit card) M M Y Y Name as it appears on Credit Card: (Print) Signature (required on credit card orders) COUNCIL USE ONLY: Budget Code: - - - - - Insurance Plan 3E July 2015
Travel Forms GP-1A, GP-1B, GP-1C, GP-1D, GP-1E Troop Activity: Request for Approval
FORM GP-1A Preliminary Application for Troop/Group Extended/Out of Council Trip For trips lasting more than 2 nights or and/or trips out of Council jurisdiction. Have your Service Unit Manager sign the form and submit to the Council Trip Representative for approval. Troop # Service Unit Program Level #of Girls in Troop/Group Number of girls participating in the trip # of adults participating Age range of girls Trip Coordinator s Name How long working with troop? Street City Zip Phone E-mail Troop/Group Leader s Street City Zip Phone E-mail Trip Destination(s) Proposed Travel Dates: Departure Return Method(s) of Transportation Activities planned The troop (girls and adults) has taken the following steps: (please check steps completed) Discussed our plans with the parents, and have decided that we are mature enough and work well enough together to benefit from the trip as a valuable experience Held a meeting with all parents to present the idea, and secured their willingness to support the trip if it is approved Page 1 of 2
Understand the Application for Troop Money-Earning Projects must be approved prior to activity Reference Safety-Wise and GSUSA and GSCC policies and procedures while trip planning Have attached tentative budget and possible ways to finance the trip Have attached agreed upon plan for handling the troop funds if some members of the troop choose not to Participate Have an alternate plan for using the money earned in case the trip does not materialize Have an alternate plan to cover expenses in the case of trip participant cancellation I have discussed and reviewed the above plans with the Troop/Group Leader and give my preliminary approval for this trip. Service Unit Managers Printed Name Service Unit Managers Signature Date Girl Scout of Citrus 341 N. Mills Avenue, Orlando, FL 32803 407-896-447 www.citrus-gs.org Page 2 of 2 Preliminary Application for Extended/Out of Council Trip FORM GP-1A July 2015
FORM PG-1B Roster of Participants with Emergency Contact Information First Name Last Name Emergency Contact Relationship Phone (Day) Phone (Cell) Girl Scout of Citrus 341 N. Mills Avenue, Orlando, FL 32803 407-896-447 www.citrus-gs.org Roster of Participants with Emergency Contact Information FORM PG-1B July 2015
FORM GP-1C Proposed Itinerary for Troop/Group Extended/Out of Council Trip Troop # Service Unit Program Level #of Girls in Troop/Group Departure: Date: Time: Place: Return: Date: Time: Place: Transportation: ITINERARY: Date Location Activity Girl Scout of Citrus 341 N. Mills Avenue, Orlando, FL 32803 407-896-447 www.citrus-gs.org Proposed Itinerary for Extended/Out of Council Trip FORM GP-1C July 2015
FORM GP-1D Budget Worksheet for Troop/Group Extended/Out of Council Trip Troop # Service Unit Program Level #of Girls in Troop/Group # of Adults: # of Non-Girl Scout Members: Expenses Income Food: $ Money Earning Projects: Hotel/Site Rental: $ Cookie Sale Profits: $ Transportation: Fall Product Sale Profits: $ Gasoline: $ Donations: $ Air/Bus/Train Fare: $ Vehicle Rentals $ Participant Fees Other: $ Girl Fees: $ Participant Insurance: $ ($ x people x days=$???) Adult Fees: $ Program: Admission Fees: $ Other Program Costs: $ Other: $ Postage/Phone: $ Other: $
First Aid Supplies: $ Other: $ Miscellaneous: $ Subtotal: $ Contingency Expenses: $ Expense Total: $ Income Total: $ Girl Scout of Citrus 341 N. Mills Avenue, Orlando, FL 32803 407-896-447 www.citrus-gs.org Budget Worksheet for Extended/Out of Council Trip FORM GP-1D July 2015
FORM GP-1E Trip Report for Troop/Group Extended/Out of Council Trip Complete and return Report Form to the Council Service Center within one month after the trip. Keep a copy for your troop records: Trip Coordinator Troop # Service Unit Trip Destination(s) Departure Date Return Date Actual Number of participants on trip: Adults: Female Male Girls Health & Safety: Please list below all First Aid treatment for burns, cuts, sprain, etc. and treatment for any illness or injury. (Use separate sheet if necessary). If you filed any accident insurance claims, please give details on a separate sheet. Date Name Injury/Illness Treatment By Whom Finances: Estimated Cost Total Cost Balance Actual Costs: Transportation Overnight Lodging Meals Program Other Total Cost of Trip
Transportation: Any Comments? Program: Briefly explain the highlights of your trip, any changes in plans, how the girls plan to share the experience with others and the results of evaluations with girls. Use a separate sheet if necessary: Girl Scout of Citrus 341 N. Mills Avenue, Orlando, FL 32803 407-896-447 www.citrus-gs.org Trip Report for Extended/Out of Council Trip FORM GP-1E July 2015
Girl Scouts of Citrus Council 341 North Mills Ave., Orlando, FL 32803 407-896-4475 / 407-894-0966 FAX www.citrus-s.org TROOP ACTIVITY: REQUEST FOR APPROVAL Date Submitted: This form must be submitted to the service unit manager or troop consultant AT LEAST ONE MONTH in advance for a camping trip or an activity out of council jurisdiction or TWO WEEKS for all other planned activities. The original will be kept in the service unit files and one copy will be returned to the troop leader. Troop/Group #: Grade Level: Service Unit: Type of activity: (check one) day trip overnight trip troop camping Description of activity: Dates and times of activity: from on, to on Number of girls participating: Destination: Means of transportation: Drivers: Names of ALL adults accompanying the troop: I have checked all Safety Activity Checkpoints applicable: Horseback Riding Challenge Courses Water Activities Fishing Other Lifeguard/or person with required certification (if applicable) Name: Emergency Contact Person: Phone: Day: Cell: Eve: ITEMS TO BE TAKEN ON THE TRIP OR PEOPLE THAT MUST PARTICIPATE: * Emergency Procedures information * A first aider or equivalent (if required) * Parent Permission for each girl Name: * First aid kit * A certified Troop Camper (if appropriate) * Medical insurance claim form Name: * Accident report * Correct adult/girl coverage per grade level (see Safety Activity Checkpoints)
Current balance in troop treasury: $ Cost of activity: (Does not need to be completed if there is no cost) Transportation Food Program Insurance Other Emergency Fund TOTAL COST $ Troop/Group Volunteer signature Amount to be paid from troop treasury: Amount to be paid by girl: Girl signature APPROVED: Service Unit Manager or Troop Consultant Date NOT APPROVED for the following reason(s): Girl Scout of Citrus 341 N. Mills Avenue, Orlando, FL 32803 407-896-447 www.citrus-gs.org Troop Activity Request for Approval July 2015