Fill and Sign the Workers Compensation Disputed Claim for Compensation Form

Plan 3E Enrollment Form for Girl Scout Councils Underwritten by United of Omaha Life Insurance Company 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 must be received by Mutual of Omaha prior to 12:01 a.m. of the first day of the Girl Scout event. FROM: Name of Council ______________________________________________ Address ______________________________________________ (Please complete the address portion in full. This will be used to return the Council’s verification copy.) City _______________________ State ______ ZIP ________ Council approval is required — forms without the appropriate Council signature cannot be processed; troop leaders should not submit enrollments directly to Mutual of Omaha. Council Code No. ■ ■ ■ Leader name or 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 Name and Location of Event Beginning Date Ending Date SAMPLE: CAMPING 2/5/XX (1) 2/9/XX (2) Number of Number of Participants Days 25 (3) (4) (5) Number Participant Days (1 x 2) Premium Each Day @ 29¢ Total (3 x 4) 125 $ .29 $ 36.25 5 1. .29 2. .29 3. .29 4. .29 5. .29 .29 N/A TOTAL N/A 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 Signature ✗_______________________________________ Title ______________________________ Date _______________ FOR HOME OFFICE USE ONLY Verification of Coverage to Council SGS21 Approved as Submitted ✗ _________________________ /___ / ___ Approved with Change Marked ✗ __________________ /___ / ___ M19060_0507 Signature Date Signature Date