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AUSTRALIAN RUGBY GOLDEN OLDIES (ABN 21124476615) 2009 Insurance Registration & Renewal Form Instruction: This form will register your team for the ARGO Sports Insurance Scheme for the 2009 season. Insurance will commence from the date the form is received by the insurance broker (fax acceptable) conditional upon premium payment within 14 days of commencement of insurance cover. All insurance registration forms must be received by 31/3/09. The new cover will expire 31/3/2010. Complete the reverse side of this form and return to the insurance brokers. ARGO Insurance Broker Detail: Barry Killham C/- DHB&Associates Pty Ltd (FSR 241056) PO Box 5174 Elanora Heights 2101 Ph: 02 99707577 Fx: 02 99707077 Email email@example.com Summary Of Insurance Cover: Type Of Cover Sum Insured Section A General Liability Insurance ($1,000 excess) $20,000,000 Sports Injury - Capital Benefits (death and disability) $150,000 - Non Medicare Expenses ($100 excess) $3,500 Section B Weekly Benefits - Loss of Income benefit $300.00 per week - maximum 52 weeks and 14 day excess NB: Additional information on the insurance coverage is available on the Australia Golden Oldies website www.argorugby.com.au or by contacting the insurance broker direct. A master policy is held with ARGO and upon receipt of your teams application form and premium payment, a certificate of insurance will be issued direct to your team. Important Insurance Conditions: All players must be over 35 years of age. 1. All games must be played under strict Australian Golden Oldie Rules 2. Policy wording and Product Disclosure Statement on www.argorugby.com.au 3. Teams must maintain a club membership register. 4. Cover is worldwide and teams travelling overseas should carry additional travel insurance which is available through ARGO website. 5. A Certificate Of Insurance will be issued once premium paid and registration form received. 6. Cover includes referees who are a) a registered member of insured team, or b) officiating for a insured team. Cost Of Insurance Cover: (inclusive of GST and Stamp Duty) STATE Section A Section A & B NSW $872.30 $1565.30 VIC, ACT, WA & NT $902.00 $1628.00 TAS $886.60 $1599.40 QLD $882.75 $1592.25 SA $909.70 $1642.30 NB: Application/Renewal form on reverse side. AUSTRALIAN RUGBY GOLDEN OLDIES 2009 Insurance Registration & Renewal Form Instruction: Once you have read the information provided on the reverse of this form, please complete this page and submit to ARGO’s insurance broker to arrange insurance cover. Unless otherwise agreed, cover will commence upon receipt of your application and will expire 31/3/2010. ARGO Insurance Broker Detail: Barry Killham C/- DHB&Associates Pty Ltd (ABN33003714109) PO Box 5174 Elanora Heights NSW 2101 Ph 02 99707577 Fx 02 99707077 Email firstname.lastname@example.org Team Details: Team Name: Contact: Phone: Fax: Postal Address: P/CODE Email : Address Of Usual Home Ground: Insurance Cover Selected: (please indicate your choice) No. Teams Section A Section A & B Total Premium to be paid $ **PLEASE MAKE CHEQUES PAYABLE TO DHB & ASSOCIATES PTY LTD** Indication of playing ages Estimated Number Age <36-50 Age >51-60 Age > 61-80 Age > IMPORTANT: Please attach list (names and address) of all club members. SIGNED: ……………………………………………………………………DATE: …………….
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