Mutual of Omaha - Purchase of Plan 2 Insurance

This form is for the purchase of Plan 2 insurance which covers accidents only for non-registered Girl Scout members. Other types of insurance plans are available here.

The cost for insurance is set by Mutual of Omaha and is subject to change without notice. The estimated cost is calculated as follows: number of non-registered participants x number of trip/event days x 11 cents. For example 25 participants x 5 days x 11 cents = $13.75. NOTE: The minimum insurance cost is $5.00 therefore if the total calculated cost is less than $5, then the amount owed is $5.00.

This form needs to be submitted 2 weeks prior to an event/trip for ample processing time. Submitting this form in less than 2 weeks prior to your event/trip may result in an inability to secure Plan 2 additional insurance.

If you need to purchase insurance for more than 12 events/trips, please use the writable form found here.

Please contact Customer Care at customercare@gsofct.org or 1-800-922-2770 with any questions.

Please be sure to complete the form in its entirety and enter payment information. You must click "SUBMIT" in order for your insurance request to be processed.
Mutual of Omaha - Plan 2 Insurance Form
Name of Person Completing Form*

First NameLast Name
Preferred Phone Number*
Email*
example@example.com
Event/Trip #1
Is this insurance for a:*

TripEvent
Is this a Troop or Service Unit Event/Trip?*

TroopService Unit
Troop Number*
Service Unit Name*
Name of Event/Trip (i.e. Ice Skating)*
Location/Venue of Event/Trip*
Address of Event/Trip Venue*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Number of Participants Needing Insurance*
Do you need to purchase insurance for another event?*

YesNo
Event/Trip #2
Is this insurance for a:*

TripEvent
Is this a Troop or Service Unit Event/Trip?*

TroopService Unit
Troop Number*
Service Unit Name*
Name of Event/Trip (i.e. Ice Skating)*
Location/Venue of Event/Trip*
Address of Event/Trip Venue*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Number of Participants Needing Insurance*
Do you need to purchase insurance for another event?*

YesNo
Event/Trip #3
Is this insurance for a:*

TripEvent
Is this a Troop or Service Unit Event/Trip?

TroopService Unit
Troop Number*
Service Unit Name*
Name of Event/Trip (i.e. Ice Skating)*
Location/Venue of Event/Trip*
Address of Event/Trip Venue*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Number of Participants Needing Insurance*
Do you need to purchase insurance for another event?*

YesNo
Event/Trip #4
Is this insurance for a:*

TripEvent
Is this a Troop or Service Unit Event/Trip?*

TroopService Unit
Troop Number*
Service Unit Name*
Name of Event/Trip (i.e. Ice Skating)*
Location/Venue of Event/Trip*
Address of Event/Trip Venue*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Number of Participants Needing Insurance*
Do you need to purchase insurance for another event?*

YesNo
Event/Trip #5
Is this insurance for a:*

TripEvent
Is this a Troop or Service Unit Event/Trip?*

TroopService Unit
Troop Number*
Service Unit Name*
Name of Event/Trip (i.e. Ice Skating)*
Location/Venue of Event/Trip*
Address of Event/Trip Venue*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Number of Participants Needing Insurance*
Do you need to purchase insurance for another event?*

YesNo
Event/Trip #6
Is this insurance for a:*

TripEvent
Is this a Troop or Service Unit Event/Trip?*

TroopService Unit
Troop Number*
Service Unit Name*
Name of Event/Trip (i.e. Ice Skating)*
Location/Venue of Event/Trip*
Address of Event/Trip Venue*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Number of Participants Needing Insurance*
Do you need to purchase insurance for another event?*

YesNo
Event/Trip #7
Is this insurance for a:*

TripEvent
Is this a Troop or Service Unit Event/Trip?*

TroopService Unit
Troop Number*
Service Unit Name*
Name of Event/Trip (i.e. Ice Skating)*
Location/Venue of Event/Trip*
Address of Event/Trip Venue*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Number of Participants Needing Insurance*
Do you need to purchase insurance for another event?*

YesNo
Event/Trip #8
Is this insurance for a:*

TripEvent
Is this a Troop or Service Unit Event/Trip?*

TroopService Unit
Troop Number*
Service Unit Name*
Name of Event/Trip (i.e. Ice Skating)*
Location/Venue of Event/Trip*
Address of Event/Trip Venue*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Number of Participants Needing Insurance*
Do you need to purchase insurance for another event?*

YesNo
Event/Trip #9
Is this insurance for a:*

TripEvent
Is this a Troop or Service Unit Event/Trip?*

TroopService Unit
Troop Number*
Service Unit Name*
Name of Event/Trip (i.e. Ice Skating)*
Location/Venue of Event/Trip*
Address of Event/Trip Venue*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Number of Participants Needing Insurance*
Do you need to purchase insurance for another event?*

YesNo
Event/Trip #10
Is this insurance for a:*

TripEvent
Is this a Troop or Service Unit Event/Trip?*

TroopService Unit
Troop Number*
Service Unit Name*
Name of Event/Trip (i.e. Ice Skating)*
Location/Venue of Event/Trip*
Address of Event/Trip Venue*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Number of Participants Needing Insurance*
Do you need to purchase insurance for another event?*

YesNo
Event/Trip #11
Is this insurance for a:*

TripEvent
Is this a Troop or Service Unit Event/Trip?*

TroopService Unit
Troop Number*
Service Unit Name*
Name of Event/Trip (i.e. Ice Skating)*
Location/Venue of Event/Trip*
Address of Event/Trip Venue*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Number of Participants Needing Insurance*
Do you need to purchase insurance for another event?*

YesNo
Event/Trip #12
Is this insurance for a:*

TripEvent
Is this a Troop or Service Unit Event/Trip?*

TroopService Unit
Troop Number*
Service Unit Name*
Name of Event/Trip (i.e. Ice Skating)*
Location/Venue of Event/Trip*
Address of Event/Trip Venue*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Number of Participants Needing Insurance*
Troop/Service Unit Banking Information
Name on Bank Account *
i.e. Troop 12345
Name of Banking Institution*
Routing Number*
9 digits
Account Number*
Up to 15 Digits
Confirm Account Number*
Up to 15 Digits
PLEASE READ! November 2022

Due to recent late payemts from troops for Plan 2 coverage, GSOFCT had to pay troop fees in order to remain in good standing with Mutual of Omaha. Please ackowledge the 2 checkboxes below before submitting your form.
Signature*

Clear
Please review all information for accuracy before clicking "Submit" below.
Should be Empty:

Mutual of Omaha - Plan 2 Insurance Form

Event/Trip #1

Event/Trip #2

Event/Trip #3

Event/Trip #4

Event/Trip #5

Event/Trip #6

Event/Trip #7

Event/Trip #8

Event/Trip #9

Event/Trip #10

Event/Trip #11

Event/Trip #12

Troop/Service Unit Banking Information