Individual Personal Accident Cover - Eastern Football League Insurance

If you are interested in obtaining cover as an individual over and above the cover arrange via Eastern Football League please complete the form below and we will arrange a no obligation quotation for Individual Personal Accident Insurance.

Applicant Name:*
First Last
Applicant Postal Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Best Contact Phone Number:*
Are you happy to receive all correspondence Via Email?*
Email
Applicant Occupation:*
Applicant Date of Birth:*
DD slash MM slash YYYY
Applicant Gender:*
Applicant Height:*

Enter height in centimetres
Applicant Weight:*

Enter weight in Kilograms
Are you a smoker?*
PERSONAL DETAILS
Employment Category:*
Type of Cover:*
Are you a permanent resident of Australia?*
Do you intend working outside of Australia?*
Is your current business a new venture that’s been operating less than 12 months?*
EARNINGS DETAILS
What is your average weekly income?*
Subtract your weekly expenses incurred Earning the above income:*
Plus fixed expenses (if required):*
Insurable weekly earnings will be:*
COVERAGE REQUIREMENTS
Capital Benefit Sum Insured (Death):*
Injury – Weekly Benefit Sum Insured: (Can not exceed average weekly income)
Injury - Benefit Period:*
Injury – Exclusion Period (Excess)*
Would you like Illness Cover?*
Illness – Weekly Benefits: (Can not exceed average weekly income)
Illness – Exclusion Period (Excess)*
PERSONAL INSURANCE HISTORY
In the last 10 years have you:
Received treatment or advice from a Medical Practitioner (including but not limited to a Doctor, Chiropractor, Physiotherapist, Psychiatrist or Naturopath) in relation to;
Disorders of Circulatory System – Including heart, arteries; Lungs, tuberculosis or other disorders of the respiratory system;
Kidney, bladder, liver, spleen, or other disorders of the genitor-urinary system;
Depression, psychological, psychiatric or personality disorder;
Cancer or tumor;
Drug or alcohol dependence;
Diabetes – Type 1;
HIV, AIDS or AIDS related conditions;
Hepatitis C
Do any of the above apply to you?*
Please provide relevant information here
Are you entitled to claim Benefits from Workcover?*
Are you entitled to claim Benefits from any other Existing or intended Accident or illness Policy?*
PERSONAL ACTIVITY DETAILS
Do you participate in any hazardous pursuits or activities, including but not limited to; Motor Sports in any form, rock climbing or mountaineering, water skiing, snow skiing, snow boarding, horse riding, canyoning, motor cycling, hang gliding, parachuting, abseiling, kite surfing, mountain biking, scuba diving, football ( all codes) and any other body contact sports?*
Please provide relevant information here
Are there any hazardous duties associated with your occupation? (e.g: Explosives/Dangerous Substances, Working at heights (above 2 stories), Mining Operations)*
Please provide relevant information here
The above information has been supplied by me and is true and correct*
- Please tick to agree to the above statement.

PERSONAL DETAILS

EARNINGS DETAILS

COVERAGE REQUIREMENTS

PERSONAL INSURANCE HISTORY

PERSONAL ACTIVITY DETAILS

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