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Girl Scouts of the USA

alt Enrollment Forms
for Girl Scout Optional Plans 2, 3P, 3E or 3PI

1. Complete the enrollment form in its entirety.
Only one plan may be selected per event.

2. Once completed and submitted, you will be sent an e-mailed copy for your records. Please mail one copy to Mutual of Omaha.

3. Council approval of all enrollment forms is required.

4. Payment in full must be included with the enrollment form submission.

Coverage Choice
The Optional Plan of Insurance desired is (please only one optional plan selection per enrollment form):

Plan 2	Excess Coverage	Accident Only	$0.11 Per Day Premium
Plan 3P:	Primary Coverage	Accident & Sickness	$0.67 Per Day Premium
Plan 3E:	Excess Coverage	Accident & Sickness	$0.29 Per Day Premium
Plan 3PI*:	Primary Coverage	Accident & Sickness & Travel Assist	$1.17 Per Day Premium

United of Omaha relies on the Council to validate/authorize both Enrollment Forms and Claim Forms prior to processing. Enrollment Forms and premium must be received prior to the beginning date of any event, United of Omaha cannot back date coverage. Claim Forms and appropriate bills should be filed/submitted as near the date of the accident as reasonably possible.

Mutual of Omaha Insurance Company is licensed in all 50 states; United of Omaha Life Insurance Company is licensed in all states but New York. In New York, Companion Life Insurance Company, Lynbrook, NY, underwrites life insurance and annuities.

AFN 31231