ADDITIONAL INSURANCE REQUEST FORM
INSTRUCTIONS: Review the Additional Activity Insurance Procedure.
Complete an Additional Insurance Request Form – one (1) per event.
Include a check payable to GSWPA and submit eight (8) weeks prior to event to your membership manager.
If this is for a trip or high-risk activity: Mail with your Trip and High-Risk Activity Application.
A minimum payment of $5 is required on all additional insurance requests. DO NOT send cash.
If submitting more than one request, they can be combined to a single $5 payment.
FORM SUBMITTED BY (Please print)
Name:
Address
Street
City
Phone
State
Zip
Email
ADULT IN CHARGE OF ACTIVITY (if different from adult submitting)
Name
Address
Street
City
State
Phone
Zip
Email
DESCRIPTION OF EVENT/ACTIVITY
Event Name/Description:
Location Name
Address
Street
City
State
Zip
Beginning Date
Ending Date
Event Duration (number of days)
(Each portion of a day is counted as a full day)
Number of registered Girl Scouts attending:
(Extended Event (3E) Insurance is required for
registered Girl Scouts when activity lasts longer than 2 overnights)
Number of non-members attending:
any activity.)
(Insurance is required for all non-members participating in
COMPLETE THE CHART BELOW FOR THE TYPES(S) OF INSURANCE
COVERAGE NEEDED–See example below and review the Additional Activity Insurance
Procedure for descriptions of the different plans.
PLAN
Number of
Participants
Example
15
Number of
Days
Number of participants X Premium
Number of days
each day
2
30
@.11
2
Participant
@.11
3E
Extended Event
@.29
3P
Extended Event
Primary
@.70
3P-I
International
Extended Event
@$1.17
155
TOTAL DUE
(Minimum $5)
$3.30 ($5)