Girl Scouts, Hornets’ Nest Council

7007 Idlewild Road  Charlotte, NC 28212

704-731-6500, Outside Mecklenburg 800-868-0528

Website:

Supplemental Insurance Request

Supplemental Insurance is required for trips lasting more than 2 consecutive nights (or 3 nights if one is a federal holiday). Supplemental Insurance is also required for non-registered participants at any Girl Scout activity. Non-registered participants mightinclude boys, non-registered adults, younger siblings, etc.

  • Before completing this application ensure each participant is the appropriate age to participate in the program. You cannot insure non-participants. (For instance, a 4-year old tag-a-long at an archery event cannot be insured since the child is not old enough to participate in archery.)
  • Before completing this application, refer to the Volunteer Essentials manual found at and review Safety Activity Checkpoints found at for specific emergency procedures and first aid safety guidelines for each activity. Be sure to follow all standards that apply to your trip/activities.
  • Return this form with insurance payment 2-weeks in advance to GSHNC-Reservations. Insurance payments are not accepted the day of the event.
  • Send a check to GSHNC, payable to Mutual of Omaha, along with this completed form. See the chart below to calculate the amount. There is a minimum charge of $5.

General

Troop Leader Name / Troop Number / Service Unit
Troop Leader Street Address / City, State / Zip
Day Phone / Evening Phone / Email Address
Number of registered girls attending:
______/ Number of registered women attending:
______/ Number of registered men attending:
______/ Non-registered participants attending:
Men: ______
Women: ______
Children: ______/ TOTAL NUMBER OF PARTICIPANTS ATTENDING: ______

Trip & Insurance Information

Destination or Event Name / Complete Address / Mileage (one way)
Departure Date: / Departure Time: / Return Date: / Return Time:
To calculate the amount, you must count each day of the trip starting with the day of departure and including the day of return.
There is a minimum charge of $5.Send a check to GSHNC, payable to Mutual of Omaha, along with this completed form.
Plan 2 – Accident only: Total # of Enrollees ______x # of Days ______x 11 cents = $______
Plan 3E – Accident and Sickness: Total # of Enrollees ______x # of Days ______x 29 cents = $______
Plan 3P – Accident and Sickness**: Total # of Enrollees ______x # of Days ______x 70 cents = $______
Plan 3PI – International Accident and Sickness: Total # of Enrollees ______x # of Days ______x $1.17 = $______
**Mutual of Omaha serves as the primary insurance.

Supplemental_Insurance_Request_P 5/10/2016