TRAVEL INSURANCE PROPOSAL
Name: /
Age: /
Competing Athlete: Yes/No
Period of Travel: /
Destination/Route:
Cover: /
In accordance with ACE Travel Policy WGRG701196.
Baggage: / Items which exceed $5,000 on which I require cover (premium 1.5% of full value).
1.
2.
3.
Premium: / $8.00 for Athletes and $6.50 for Non-Athletes per day.
Declaration / (a) I am not aware of any circumstance likely to lead to cancellation or curtailment of the journey. I have not withheld any information likely to affect acceptance of this insurance and I will notify the company of any change in circumstance or health occurring prior to departure.
(b) I am not travelling overseas with the intention of receiving medical treatment.
(c) During the 30 days immediately preceding the departure date I have not been prevented by injury or sickness from attending to my normal duties or activities for more than 5 days in total as a result of the pre-existing condition or if not in full time employment confined to bed for more than 5 days. This condition does not apply to those travellers when travelling solely between Australia and New Zealand.
(d) That in respect of any medical or physical condition suffered in the past 12 months (other than of a minor nature) I have obtained clearance from my usual doctor or specialist to undertake this journey.
(e) I am not suffering from a terminal illness.
(f) I am aware if I need to make a claim there will an excess to pay (see over the page for details)
Signed: Date :
Address:
Note: If sickness or disease is not covered due to declaration (c) and cover is required please contact Jardine Lloyd Thompson (Ph 0800 111 644)GYMSPORTS NEW ZEALAND
SUMMARY OF TRAVEL POLICY
DESCRIPTION / SUM INSURED (PER PERSON)Medical Expenses / Unlimited
Interruption and Curtailment / Included under Medical Expenses Section under the same Sum Insured.
Loss of Deposits / $30,000
Baggage and Personal Effects
Electronic Equipment / $10,000
(limit of $2,000 any one item unless specified)
$10,000 - $350
Deprivation of Baggage / $5,000
Money / $5,000
Personal Accident / $250,000
Personal Liability / $5,000,000
Rental Vehicle Excess Cover / $5,000
Premium Rate Per Day / $8.00 Athletes or $6.50 Non-Athletes
Note: None Competing Children under age 16 Travelling with a parent are free of charge.(Athlete charge applies to under 16 year olds who are travelling to compete.)
If you need to make a claim there will be a excess, these are below.
DEDUCTIBLES / EXCESSES:
Section 1 - Weekly Benefits - Injury 14 Days
Section 4 - Medical & Additional Expenses $25
Section 4 - Cancellation & Curtailment Expenses $500
Section 6 - Loss of Deposits $250
Section 7 - Baggage, Personal Effects & Tools of Trade $100, Electronic Equipment $350, Deprivation of Baggage, Money & Travel Documents $250
Please note this is a summary of cover only. A full policy document has been issued to GymSports New Zealand.