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AUSTRALIAN RUGBY GOLDEN OLDIES

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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 barry@dhbi.com.au

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 barry@dhbi.com.au
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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