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Your Name:
Your Phone No:
Your Email:
Brokerage Name:
Australian Financial Services Licence No:
Club/Association/Business Name:
Business Address:
Annual Turnover:
Member Numbers (if applicable)
Current Insurer:
Expiry Date:    
Holding Broker:
Please provide details on the business/club/association to be insured:

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:     
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