Sports Underwriting Australia Pty Ltd

Sporting Clubs & Associations

Your Name:
Your Phone No:
Your Email:
Brokerage Name:
Australian Financial Services Licence No:
Club/Association Name:
Business Address:
Annual Turnover:
Current Insurer:
Expiry Date:
Holding Broker:

Please advise what sports the insured is involved in and the number of members to be covered by this insurance. If more than one sport please list down individually and specify the members for each sport.

	Sport	Formal Risk Management Procedures	Senior Members	Junior Members	Coaches/Refs/Officials
1.
2.
3.
4.

Please select the cover you require:

Public/Products Liability & Professional Indemnity

Yes NO

Player Accident cover:

Yes NO

Property Cover

Yes NO

Has the insured had any claims in the past 5 years that would be covered by the proposed insurance?

Yes NO

Is there any other information you would like to provide?

Yes NO

Your Name:
Date:
Please press the submit button. A response will be sent to your nominated email address.