Northern Ireland Soccer Insurance Proposal Form

Transcription

1 Northern Ireland Soccer Insurance Proposal Form

2 A simple personal accident / public liability policy for amateur football clubs Please note this is a summary of the features of this product. Full terms and conditions can be found in the policy document, a copy of which is available on request. This summary should be read in conjuction with our Terms of Business and Important Disclosure of Information documents. Realistic level of personal accident benefits Hospitalisation benefit Dental expenses cover Cover whilst playing, training and travelling to matches Prompt claims service Personal Accident (A TEAM CONSISTS OF 20 PERSONS) CLUB MEMBERS would be covered whilst: (a) Playing or officiating for the Club at Home or Away Fixtures. (b) Taking part in training organised by the Club. (c) Travelling (not by Air/Motor Cycle) directly to or back from Home or Away Fixtures. (d) Five a side Teams are automatically included providing they are from the 20 persons.

3 Personal Accident Benefits & Premiums Scheme A B C D E 1. Death occuring within 24 months of accident. 2,000 5,000 10,000 15,000 20, Loss of one or more limbs or eyes. 2,000 5,000 10,000 15,000 20, Permanent Total Disablement from gainful employment of any and every kind. 2,000 5,000 10,000 15,000 20, Temporary Total Disablement (weekly payments up to a maximum of 52 weeks) excluding the 1st week of disablement A Payment of 10 for each night spent in Hospital. 6. Up to 250 towards the cost of Emergency Dental Fees, excluding the first 25 of each claim. The Players own Dentist must be used. Premium per Team Premiums include insurance premium tax. Public Liability Covers your legal liability to pay for compensation and claimants costs and expenses for accidental bodily injury or accidental loss of or damage to property sustained by members of the public and occurring in connection with the sport. Rates 1-2 teams 1million limit Each additional team 1 million limit teams 2million limit Each additional team 2 million limit (cover assumes no club house otherwise, please contact to Towergate Risk Solutions Poole) Prices include Insurance Premium Tax Clubs with their own pitch are ineligible under this scheme. Please call for a quotation on

4 Proposal Form Full Name of Club Name and Address of Secretary Post Code Tel. No address Which League (if any) do you belong to? Number of Teams run by the club (N.B. All teams run by the club must be included) Personal Accident Insurance Which scheme do you require? (please tick) A B C D E Details of any Personal Accident claims during the last 3 years: Personal Accident Premiums Scheme x No. of teams = (A) Public Liability Insurance Limit of cover required: 1 Million 2 Million Public Liability Premiums (B) Details of any public liability claims during the last 3 years: Total Premium Premium (A) + Premium (B) + 10 policy fee = Cheques to be made payable to Towergate Risk Solutions Poole.

5 Material Facts Failure to disclose a material fact (any fact likely to influence the Company s acceptance or assessment of this proposal) will render this insurance voidable. If you are in any doubt about the facts which might be considered material you should disclose them. e.g. Previous claims made by the club. Data Protection We may use the personal details you give us, or which are supplied by third parties, to provide you with a quotation, to administer your policy, to search the files of credit reference agencies who may keep a record of the search, to support the development of our business by including your details in customer services and for market research and compliance business reviews. We may also share these details with other insurance organisations to help offset risks, to help administer your policy and handle claims and prevent fraud. We will store your details on computer but will not keep them for longer than necessary. Under the terms of the Data Protection Act 1998 you are entitled to a copy of all the information we hold about you. Declaration I/We declare that to the best of my/our knowledge or belief the particulars and statements given in this proposal and any other information provided in connection with this proposal are true and complete and this proposal, declaration and information shall be the basis of the contract between myself/ourselves and Groupama Insurance. I/We agree to accept Groupama Insurance s standard form of policy and endorsements for this insurance. Signed X Date X

6 Also available Youth football insurance Sports coaches Clubhouses Sports clubs Social clubs Mini-bus insurance Golf equipment Golf clubs We can also arrange insurance for many other areas please contact us for further information Call Towergate Risk Solutions on Lines open Monday to Friday 9.00am to 5.00pm For further information or in the event of a claim, please contact: Towergate Risk Solutions Poole Towergate House, Upton Road, Poole, Dorset BH17 7AG Tel: Fax: Underwritten by: Groupama Insurance Company Limited. Registered Office Groupama House, Minories, London EC3N 1DE Registered in England No Authorised and regulated by the Financial Services Authority Towergate Risk Solutions Poole is a trading name of Towergate Underwriting Group Limited Registered Address: Towergate House, 2 County Gate Staceys Street, Maidstone, Kent ME14 1ST Registered in England No Authorised and regulated by the Financial Services Authority 0378/038/PF/03.06/3966