1. The leader completes all information requested under the Girl Scout Leader Statement section
of the Mutual of Omaha-Girl Scouts of the USA Claim Form to the best of her ability, then signs
and dates the form. It is imperative that all information is included to expedite processing and
to avoid delay.
2. The claim form must be given to the claimant for completion of all identification and insurance
information. If the injury involved a minor, the claim form is given to the parent/guardian for
completion and signature in order to be processed.
3. The claimant or parent/guardian will then:
Complete the Claimant Information section, including original signature section and submit
any itemized bill(s) complete with diagnosis, date(s) and procedure code(s).
Retain one copy of the completed claim form for their records.
Send the original to:
GSWPA
30 Isabella Street, Suite 107
Pittsburgh PA 15212
ATTN: Insurance claim
for validation along with any available bills for covered expenses which have been incurred.
Claims cannot be processed without council signature.
If bills are received after the initial claim is submitted, they should be submitted to Mutual
of Omaha according to the directions given by Mutual of Omaha after the claim is received.
NOTE: The address section on the claim form must be the Claimant’s Home Address, not the
Council or Resident Camp address or the address where the covered event was held.
Council Procedures:
1. The council receives the completed Mutual of Omaha-Girl Scouts of the USA Claim Form and
reviews for:
membership status or purchase of additional insurance,
eligibility, and
presence of a bill and that the activity information provided is sufficient to confirm that
the claim is for a Girl Scout-related accident or illness.
2. A Council official must sign the form. Mutual of Omaha relies ۈ H