Accident and Sickness Insurance Request Form

Accident and Sickness Insurance Request Form

Accident and Sickness Insurance is required for cruises and international travel and is optional for extended or long-distance domestic travel.

Insurance Information (Please Read Before Purchasing)

Insurance must be purchased in advance. While you may purchase insurance at any time after submitting the Extended and International Troop Travel Application and before your departure date, it is recomended that you wait until the application has been approved and about 15-30 days before the departure date in case of any changes to your trip or roster. Once this form is submitted, GSWCF staff will recieve a notification letting us know that we need to purchase the requested insurance from Mutual of Omaha. Once the insurance is purchased we are not able to issue any refunds, and if any additional travelers are added to your roster you will need to pay at least the $5 transaction minimum to purchase additional insurance.
If you are submitting this form less than a week before your departure date, contact Yazmin Garcia (ygarcia@gswcf.org) after submitting the form to confirm that she has recieved it. In a last minute situation we can purchase the insurance up to the **weekday before** the departure date (at the latest), but please submit your requests early to assure someone is available to process your request.
Once we have purchased your insurance plan from Mutual of Omaha, a copy of the the confirmation email will be forwarded to you.
Only one plan should be purchased per trip, covering all travelers under the same plan.
Plan 3PI is required for cruises and international travel. For this plan you will need to enter the names and ages for each traveler.
There is a transaction minimum of $5.00. If your total is less than the minimum, you will be charged a total of $5.00.

Plan Name	Coverage Type*	Coverage	Premium per person/per day
Plan 3P	Primary Coverage	Accident & Sickness	$0.70 per day/pp
Plan 3PI	Primary Coverage for International Travel	Accident & Sickness & Travel Assist	$1.17 per day/pp

Coverage includes Accidental Medical and Dental Expense benefits

* Primary Coverage: Benefits are not subject to Non-Duplication Provision

Troop/Trip Information
Your Name*

First NameLast Name
Email*
example@example.com
Phone Number*
5-Digit Troop Number*
Service Unit*
Travel Dates (Insurance must be requested at least the business day before your departure. If purchasing less than a week in advance, please see instructions above.)*
Number of Travel Days - This number must include both the departure and return days. For example, if you are leaving on Friday afternoon and returning Tuesday morning, the number of travel days would be 5.
Trip Destination(s)*
Is this trip a cruise or does it include any international travel?*

YesNo
*International Travel and Cruises* For each traveler please enter their name and age as of the departure date.*
Insurance Plan Selection
Insurance Plan*

3P ($0.70) - Primary Coverage3PI ($1.17) - Primary Coverage for International Travel
Total # of days of trip*
This field is automatically calculated based on the departure and return dates that you entered. Please remember when calculating the total number of days, the departure and return days are included. For example, if the trip is 3 nights, the total number of days would be 4.
Total # of Travelers*
Calculated Cost of Insurance
Minimum Purchase

Total Cost*

USDAccident and Sickness Insurance Order Form

Payment Method
Credit	Express

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

Accident and Sickness Insurance Request Form

Troop/Trip Information

Insurance Plan Selection