Volunteer Activity Insurance Guide

GIRL SCOUTS OF ORANGE COUNTY
ACTIVITY INSURANCE VOLUNTEER GUIDE
REV. M8418_0313
TABLE OF CONTENTS
PAGE
SUMMARY OF ALL PLANS ……………………………………………………………………………………………....
2
PLAN 1: Basic Plan - Girl Scout Activity Accident Insurance for Members …………..…..………
3
PLAN 2: Optional Accident Insurance for Activities or Events ………………….………………………
4
PLAN 3E: Optional Excess Accident & Sickness Insurance for Activities or Events …………….
6
PLAN 3P: Optional Primary Accident & Sickness Insurance for Activities or Events …………… 8
PLAN 3PI: Optional Accident & Sickness Insurance for International
Activities or Events …………………………………………………………………………………………………………. 10
QUESTIONS & ANSWERS ………………………………………………………………………..………………………. 12
GIRL SCOUT ACTIVITY ACCIDENT INSURANCE
(SUMMARY OF ALL PLANS)
Plan 1 – Member Accident – The Basic Plan covers registered Members for any approved,
supervised Girl Scout activity lasting two consecutive nights or less (three nights when one
of the nights is a federal holiday).
Plans 2, 3E & 3P are options for Members and Nonmembers - must choose 1
Plan 2 – Members and Nonmembers Accident – Accident Insurance covers all members as
participants for events lasting longer than those covered by Plan 1; and all nonmembers as
participants regardless of the length of the activity/event.
Plan 3E & 3P – Members and Nonmembers Accident and Sickness – Accident and Sickness
Insurance covers all participants for events lasting longer than those covered by Plan 1.
Under Plan 3E Accident Medical expense and Dental Expense Benefits payable are subject
to the *Nonduplication Provision. (E stands for “excess” insurance, if participant has
personal Medical and Dental insurance that must be used first).
Under Plan 3P benefits are NOT subject to the *Nonduplication Provision. (P stands for
“primary” insurance, if participant does not have personal Medical and Dental insurance.)
Plan 3PI – Members and Nonmembers Accident and Sickness – Accident and Sickness
Insurance covers all participants for international trips. Not subject to the Nonduplication
provision.
NOTE:
Under Plans 2, 3E, 3P and 3PI, 100% enrollment of all event participants is
required, unless a participant is a Member and is covered under Plan 1 for the
event. There is a minimum premium charge of $5.00 for each online submission.
Insurance must be ordered for the period of time beginning with the day the
participant leaves home through to the day the participant returns home (i.e.,
event scheduled June 1 through June 5 equals five calendar days).
* Nonduplication Provision = Members and Nonmembers personal insurance is considered
primary and activity insurance is considered secondary.
PLAN 1 COVERAGE CHART – ACCIDENT INSURANCE
DIAL 911 IN AN EMERGENCY
(THIS IS SECONDARY INSURANCE TO YOUR HEALTH PLAN)
ELIGIBILITY
REGISTERED MEMBERS (girl or adult) OF GIRL SCOUT
COUNCIL SPONSORED/SUPERVISED EVENTS
COVERAGE (ANY APPROVED AND
SUPERVISED GIRL SCOUT ACTIVITY)
DATE THE TROOP LEADER RECEIVES THE MEMBERSHIP DUES
& APPROPRIATE REGISTRATION PAPERWORK (girl or adult)
BENEFITS & AMOUNTS
FOR ACCIDENTAL DEATH
$15,000
FOR ACCIDENTAL DISMEMBERMENT
UP TO $20,000
FOR PARALYSIS
$20,000
HEART OR CIRCULATORY
MALFUNCTION DEATH BENEFIT
$15,000
MEDICAL EXPENSES ACCIDENTS
PAYS UP TO $15,000
DENTAL TREATMENT
UP TO $4,000 FOR TREATMENT AND/OR REPLACEMENT OF
SOUND NATURAL TEETH
MEDICAL EXPENSES SICKNESS
NOT INCLUDED
NON DUPLICATION PROVISION
FIRST $130 THEN MEDICAL EXPENSES EXCESS TO OTHER
INSURANCE
COUNSELING BENEFIT
PAYS UP TO $2,500
INFECTIOUS EXPOSURE BENEFIT
PAYS UP TO $1,500
SURFACE AMBULANCE SERVICE
PAYS UP TO $3,000
AIR AMBULANCE SERVICE
PAYS UP TO $5,000
FOR RETURN TRANSPORTATION
EXPENSE
NOT INCLUDED
REPARTRIATION EXPENSE
NOT INCLUDED
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Please Allow at Least 10 Business Days for Processing.
Plan 2 Provides ACCIDENT ONLY Insurance for Activities that Meet the Following Criteria:
For Members
Events lasting more than TWO NIGHTS (three nights when one of the nights is an official holiday)
or activities such as recruitment events or programs where Girl Scouts is the Primary Sponsor, etc.
For Non-Members & Guests
Covers non-members as participants/attendees regardless of the length of activity/event. The most
common enrollments for this plan are for non-registered parents/guardians attending a ceremony or
Workshop.
NOT For Tagalongs
Tagalongs are NOT included and are parental responsibility. Children who come with parents/guardians
on a Girl Scout trip or activity, and are not of the age and skill level to participate in council approved
supervised activities designed for the Girl Scouts, are considered Tagalongs.
The minimum amount required for enrollment is $5.00.
Please complete this form and submit it with your payment at least 10 business days prior to your event. Rush
requests cannot be guaranteed and requests received after an event cannot be processed.
Please submit payment in the form of Check or Money Order, made payable to MUTUAL OF OMAHA.
Combine multiple events to save on enrollment fees. For details, contact 949.461.8800
Event Title :___________________________________
Location : ____________________________________
Event Description : ____________________________________________________________________________
Responsible Adult in Charge : _______________________
Troop // SU # : ____________________________
E-Mail : _________________________________________
Phone : _________________________________
Beginning Date : __________________________________
End Date : _______________________________
For multiple dates, please list each date separately on the back of this form.
1. Total # of Participants
__________
2. Total # of Days
__________
3. Line 1 x Line 2
0
4. Premium Rate PER DAY
5. Line 3 x Line 4
__________
0.11
$0.11/Day
Mail Form & Payment to:
ATTN: Office Services, Insurance
Girl Scouts of Orange County
9500 Toledo Way
Suite #100
Irvine, CA 92618
$ 0.00
__________ TOTAL DUE ($5 Minimum—if total is under $5.00)
Is This Paired with a Facility Use Form or Program Center Reservation?  Yes
If Yes, Please Provide Description below, or write “See Attached Description”
 No
“For Troop Travel Insurance, Please Use the 3E or 3PI Insurance Request Form”
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