Sports insurance application form
Sports insurance application form To have your non-QRL sanctioned carnival/event, activity/event that has non registered players participating, or other activity insured, simply complete this form and either fax, post or email it to us. We will provide you with a quotation on our specific sports insurance policy. If you have any questions when completing the form, feel free to contact Terry Berryman or Julian Jemmott either by telephone (1800 SPORT 0) or email ([email protected]). ATTENTION: TERRY BERRYMAN / JULIAN JEMMOTT – FAX: (07) 3367 5100 (or Post: GPO BOX 1113 BRISBANE QLD 4001) General details Name of club Postal address Contact details
Post code Name Phone Email
Fax
Carnival / event details Date
From:
To:
No. of seniors No. of referees
No. of Juniors (under 18) No. of Non Playing Officials
Activities being conducted Carnival / event location Players Officials Event income $
Coverage details (circle / tick if required) Public liability $20,000,000 Professional indemnity $2,000,000 Personal accident - Loss of Income Yes
Description of cover Covers the club against injury or property damage claims Covers club and officials against wrongful act, error or omission Gold
Silver
Bronze
No
Personal accident benefit comparison Capital Benefits
(Death or Disablement)
Loss of Income (7 Day Excess)
Student Assistance / Home Help (14 day excess)
Non Medicare Medical Expenses Ancillary Non Medical Expenses (travel and
GOLD
SILVER
$75,000
$50,000
BRONZE $50,000
(under 18 limited to $10,000)
(under 18 limited to $10,000)
(under 18 limited to $10,000)
$500 per week
$350 per week
$250 per week
$500 per week
$350 per week
$250 per week
$2,500 per injury
$2,000 per injury
$1,500 per injury
$1,000 per injury
$750 per injury
$500 per injury
$5,000
$3,500
$2,500
accommodation)
Funeral Expenses Signed
Date
Post code Name Phone Email
Fax
Carnival / event details Date
From:
To:
No. of seniors No. of referees
No. of Juniors (under 18) No. of Non Playing Officials
Activities being conducted Carnival / event location Players Officials Event income $
Coverage details (circle / tick if required) Public liability $20,000,000 Professional indemnity $2,000,000 Personal accident - Loss of Income Yes
Description of cover Covers the club against injury or property damage claims Covers club and officials against wrongful act, error or omission Gold
Silver
Bronze
No
Personal accident benefit comparison Capital Benefits
(Death or Disablement)
Loss of Income (7 Day Excess)
Student Assistance / Home Help (14 day excess)
Non Medicare Medical Expenses Ancillary Non Medical Expenses (travel and
GOLD
SILVER
$75,000
$50,000
BRONZE $50,000
(under 18 limited to $10,000)
(under 18 limited to $10,000)
(under 18 limited to $10,000)
$500 per week
$350 per week
$250 per week
$500 per week
$350 per week
$250 per week
$2,500 per injury
$2,000 per injury
$1,500 per injury
$1,000 per injury
$750 per injury
$500 per injury
$5,000
$3,500
$2,500
accommodation)
Funeral Expenses Signed
Date
