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Girl Scouts of the USA

Plan 3E
Enrollment Form
for Girl Scout Councils

1. Submit the completed enrollment form through the Girl Scout Council for approval.

2. Following Council approval, the Council will send the completed enrollment form and premium (made payable to United of Omaha Life Insurance Company) directly to: Mutual of Omaha, Special Risk Services, P.O. Box 31716 , Omaha , NE 68131 . Enrollment form and premium (if pay now option is selected) must be received by Mutual of Omaha prior to 12:01 a.m. of the first day of the Girl Scout event.

* Required Field

*Council Code

If you do not know your Council Code, please call 1-800-524-2324 to obtain the correct Code.

*Email Address

Name of Council

Address

City

State

Zip

*Name of person
submitting this form.

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
			(1)	(2)	(3)	(4)	(5)
Name and Location of Event	Beginning Date	Ending Date	Number of Participants	Number of Days	Number of Participant Days (1X2)	Premium Each Day @ .29¢	Total (3X4)
	MM/DD/YYYY (01/01/2006)	MM/DD/YYYY (01/01/2006)	25	5	125	$0.29	$36.25
						0.29	$
						0.29	$
						0.29	$
						0.29	$
						0.29	$
						0.29	$
						0.29	$
TOTAL	N/A	N/A				0.29	$

Check made payable to UNITED OF OMAHA LIFE INSURANCE COMPANY for the TOTAL PREMIUM shown above is enclosed. MINIMUM PREMIUM is $5.00, except that several enrollment forms included in one submission may be combined to meet the minimum.

Council approval is required — forms without the appropriate Council signature cannot be processed; troop leaders should not submit enrollments directly to Mutual of Omaha.

Pay Now

Bill Me and Pay All Activities at Month End

Check this box as your official signature.

Title

Date

Underwritten by United of Omaha Life Insurance Company

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. Coverage is not in effect until full payment of all premium is received by Mutual of Omaha. 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