OAMPS Sports Risk Management 

Increased Loss Of Income 
Benefits For Individual Members 

Basketball Australia provides Personal Accident insurance protection as a benefit of membership of clubs affiliated with them and their state bodies. A summary of the cover provided under this program can be obtained by visiting the Basketball Australia section of our website at www.oamps.com.au/basketballaustralia. 

Whilst this insurance provides valuable financial protection in the unfortunate situation where a member is injured in a basketball accident the benefits provided may not be sufficient to compensate for the income lost as a result of the injury. In association with Basketball Australia and its affiliates OAMPS Insurance brokers is pleased to make available to individual members additional loss of income benefits that will be paid over and above the standard group benefits provided. 

This additional cover is purchased on a “unit” basis, with one “unit” of benefits consisting of: 

Weekly Loss of Income Benefit - $200 per week, payable for up to a maximum period of 52 weeks, subject to a 7 day excess. Maximum benefit payable is 85% or normal weekly income earned. 

The maximum number of additional cover “units” that can be purchased is six. The same terms and conditions that apply to the group cover apply to the additional cover. 

As the individual additional cover is an endorsement to the Group policy the additional cover for all individuals will expire on 1st September 2010. 


The annual cost per unit for the individual additional cover is as follows: 
	- Base premium $60.00 
	- GST $6.00 
	- Stamp Duty $6.60 
	- Sub Total $72.60 
	- Broker Fee $10.00 
	- GST on Broker Fee $1.00 
	- Grand Total $83.60 

With a common expiry date of 1st September 2010 and with individual members applying for cover at different times, an annual cover will not necessary always result. To calculate the cost of cover in these instances, divide the Grand Total premium as per above by twelve and multiply that by the number of months for which cover is to apply, including the month in which cover commences. For example, if 2 additional units of cover is required from 20th January 2010, multiple $83.60 by 2 (2 units) divide $167.20 x 12 (equals $13.93) and multiply that by 8 (January to August inclusive), which results in an amount to pay of $111.44. 

To apply for additional Personal Accident benefits please complete the Application Form following and return to OAMPS Insurance Brokers, PO Box 852, EAST MELBOURNE, VIC, 8002. 



APPLICATION FORM FOR INCREASED LOSS OF INCOME BENEFITS 
(Name) 
(Address) 
(Business Phone) 
(Private Phone) 
(Fax) 
(Email Address) 
(Number of Units of Additional Cover required) 
(Mobile) 


Note: 
One Unit consists of: 
	- Weekly Loss of Income Benefit : $200 per week, payable for up to a maximum period of 52 weeks, subject to a 7 day excess. Maximum benefit payable is 85% or normal weekly income earned. 

Cover will commence from the date that your Application is received (subject to acceptance of the application) and Expireon 1st September 2010. If your application is not accepted you shall be advised within 7 days of receipt. 

Do you have any pre-existing medical conditions?   Yes / No

If yes, please provide details:

During the last 5 years have you: 
a) Had any Insurance declined (renewal or new business) or cancelled?    Yes / No
b) Been convicted of any criminal offence?    Yes / No
c) Had any special conditions imposed on a policy?    Yes / No
d) Had a claim on a personal accident/disability policy?    Yes / No

If YES to any of a to d above please provide details in the space below:


 
PREMIUM CALCULATION
Total Annual premium as per chart $.........., multiplied by the number of units required …… equals $.............., divided by 12 equals 

$............multiplied by the number of months to 1st September 2010 (including the month in which cover commences) …… equals 

$..............(amount to pay – payment attached). 

Cheque Attached $....................... 



CARD DETAILS
If paying by credit card please complete the authority below. 

Card Type: Visa  /  Bankcard  /  Mastercard

Card Number …………./…………./…………./…………. 

Cardholder’s Name ………………………………………………. 

Expiry Date …………/………../…………. 

Amount $............................ 

Signature ……………………………………………….. 



IMPORTANT NOTICES / DUTY OF DISCLOSURE 

Please read these notices before signing this application 

You, Your or Your’s Means -  
Each person who is shown in this form; 
Each legal entity that is shown in this form 

Your Duty of Disclosure - 
This policy is subject to The Insurance Contracts Act 1984. Under that Act You have a Duty of Disclosure. This means: 
- When You ask for cover, You must tell Your Insurer all that You know about the risk You want covered that may affect Their decision: 
	- To offer You cover; and 
	- The Terms and the cost of such cover 
- If You ask for the cover to be renewed, extended, altered or reinstated You must tell Your Insurer: 
	- If there have been any changes in what is covered; and 
	- Of all things that may increase the chances of a claim. 

If Things Change 
After Your Insurer has agreed to cover You and while You are covered You must tell Them of all changes that may increase the chances of a claim. The sort of changes that may increase the chances of a claim are if: 
- You vary the scope of activities You conduct; 
- You change the facilities You provide; 
- You increase the size of Your operations 
 
Non Disclosure 
If you don’t tell Your Insurer something that You know which may affect Their decision To offer You cover or the terms of that cover They may be allowed to: 
- Reduce that amount that They have to pay for a claim. This may mean that They would pay You nothing. 
- Cancel this policy, They may even be allowed to cancel this policy from the date that the cover started if: 
- You lie to Them 
- Deliberately keep information from Them, or 
- Mislead Them 

What You Don’t Have to Tell Your Insurer 
You do not have to tell Them of anything: 
- That reduces the chances of a claim, but, if You Do, it may let Them offer You better terms or a lower price 
- That is common knowledge 
- That they should know as a normal part of Their business 
- If They waive Your Duty of disclosure 

If You Reduce Your Insurer’s Rights 
They will not pay that part of a claim where You have by agreement limited or excluded Your rights to recover Your loss from any person or entity 


DECLARATION: 

I represent that the following statements and facts are true and that no material facts have been suppressed or misstated. I understand that completion of this form does not bind coverage. The company’s acceptance of this proposal is required before cover may be bound and the policy issued. 

Futhermore, I; 
1. have either completed all the questions on this form personally or they have been completed by somebody else on my behalf and the answers have been checked for fullness and accuracy by me. 
2. have read and understood the information concerning important notices and duty of disclosure. 
3. agree to the Insurer obtaining form my previous insurer(s) any information it may need about prior claims or insurance history. 
4. agree to the Insurer making enquiries from any third party to verify claims history and other information disclosed herein or statements made by myself in making this application. 
5. agree to the Insurer disclosing to any insurance intermediary appointed by myself or to any former or future insurer of myself the claims history or any other information as may be determined. 



Signature of the Applicant:


Dated: 
 

Please return this application form to OAMPS Insurance Brokers, PO Box 852, EAST MELBOURNE, VIC, 8002. 




Direct to your nearest branch - 1800 SPORT 1

OAMPS Insurance Brokers Ltd 

Web: www.oamps.com.au ABN 34 005 543 920 
Ref. 0482 - 11SEP09