NEW ZEALAND PROBUS ORGANISED TOUR TRAVEL INSURANCE APPLICATION WORLDWIDE inc by salazarcannon

VIEWS: 68 PAGES: 2

									® NEW ZEALAND

PROBUS ORGANISED TOUR TRAVEL INSURANCE APPLICATION WORLDWIDE (inc. Norfolk Island)
ABN: 38 726 423 979 POLICY NUMBER: 04PP005613 INSURER: ACE INSURANCE LIMITED
REFER TO THE FULL SUMMARY FOR ALL INCLUSIONS AND EXCLUSIONS AGE LIMIT: UP TO 100 YEARS – noting limitations outlined below and on summary

PROBUS CLUB: TOUR ORGANISER: POSTAL ADDRESS:

______________________________________________________________________ ______________________________________________________________________ _____________________________________________________________________ ______________________________________________________________________

CONTACT TEL NO: DESTINATION:

______________________________________________________________________ ______________________________________________________________________

DURATION OF TOUR: ______________________________________________________________________ DEPARTURE DATE: ______________________________________________________________________ _______________ @ NZ$80.00 PER PERSON PER TRIP

TOTAL NUMBER OF APPLICANTS: PLEASE NOTE:
•

• •

Fee of NZ$80.00 per person (for travel between 1st December 2007 – 30 November 2008) must be remitted to the Probus Centre – South Pacific Inc. prior to the final payment of monies to third party travel agents. Fee for Travel Insurance may only be refunded within 14 days of the application and payment being processed by Probus Centre – South Pacific Inc. All claims made will be paid out in AUD$.

Level 2 43 Hunter Street Parramatta NSW 2150 PO Box 1294 Parramatta NSW 2124 Telephone: (02) 9806 0100 Fax: (02) 9633 4779 Toll Free: 1800 630 488 NZ Toll Free: 0800 14 77 62 87 Email: probus@probus.com.au Website: www.probus.com.au

STATEMENT
I/We the undersigned have read the summary supplied and understand the conditions and excesses covered by the policy. I/We understand that there is: • An excess of AUD$500.00 is applicable for Medical and Additional Expenses for persons aged over 80 years. • An excess of AUD$100.00 is applicable for Medical and Additional Expenses for all others • The maximum sum insured payable to an insured person aged over 90 years to 100 years for Medical and Additional Expenses is AUD$5000 • No cover available for cancellation/curtailment/loss of deposit resulting from illness for persons over 80 years of age • No cover available for cancellation/curtailment/loss of deposit for persons over 90 years of age. • Where possible, this form must be signed by all applicants

NORFOLK ISLAND
• • • • • An excess of AUD$500 is applicable to persons aged 80-100 for Medical & Additional Expenses for travel to Norfolk Island An excess of AUD$500 is applicable to persons for Cancellation & Curtailment Expenses for travel to Norfolk Island An excess of AUD$500 is applicable to persons for Loss of Deposit for travel to Norfolk Island

GENERAL NOTE
The following conditions apply for those with pre-existing medical conditions: o The traveller must obtain approval from their doctor advising they are fit to travel. o The Insured Person cannot travel solely for the intention of having treatment for an existing medical condition. o The policy will not cover expenses incurred for any medication for a condition which commenced prior to the commencement of the journey and which such medication the Insured Person has been advised to continue during travel.

NAME

SIGNATURE

Level 2 43 Hunter Street Parramatta NSW 2150 PO Box 1294 Parramatta NSW 2124 Telephone: (02) 9806 0100 Fax: (02) 9633 4779 Toll Free: 1800 630 488 NZ Toll Free: 0800 14 77 62 87 Email: probus@probus.com.au Website: www.probus.com.au


								
To top