Volunteer Essentials Volunteer Essentials 2015-16 - Updated 5/31/17 | Page 143

Insurance Claim Procedure 1. The leader completes all information requested under the Girl Scout Leader Statement section of the Mutual of Omaha-Girl Scouts of the USA Claim Form (which can be found by searching for "Mutual of Omaha Claim Form" on www.gswpa.org) to the best of their ability, then signs and dates the form. It is imperative that all information is included to expedite processing and to avoid delay. 2. The claim form must be given to the claimant for completion of all identification and insurance information. If the injury involved a minor, the claim form is given to the parent/guardian for completion and signature in order to be processed. 3. The claimant or parent/guardian will then:  Complete the Claimant Information section, including original signature section and submit any itemized bill(s) complete with diagnosis, date(s) and procedure code(s).  Retain one copy of the completed claim form for their records.  Send the original to: GSWPA 30 Isabella Street, Suite 107 Pittsburgh PA 15212 ATTN: Insurance claim for validation along with any available bills for covered expenses which have been incurred. Claims cannot be processed without GSWPA staff signature.  If bills are received after the initial claim is submitted, they should be submitted to Mutual of Omaha according to the directions given by Mutual of Omaha after the claim is received.  NOTE: The address section on the claim form must be the Claimant’s Home Address, not the Council or Resident Camp address or the address where the covered event was held. Council Procedures: 1. GSWPA staff receives the completed Mutual of Omaha-Girl Scouts of the USA Claim Form and reviews for:  Accident/Incident Report on file (See Accident/Incident Procedure)  Membership status or purchase of additional insurance  Eligibility  Presence of a bill  Activity information provided must be sufficient to confirm that the claim is for a Girl Scout-related accident or illness. 2. A Council Official must sign the form. Mutual of Omaha relies on the council to verify that the claim is for a Girl Scout-related accident or illness. 3. GSWPA will retain one copy of the claim form for their records and send the original (with any bills and the original Accident/Incident form) to Mutual of Omaha Life Insurance Company.