MARTIAL ARTS STUDENT ACCIDENT INSURANCE APPLICATION FORM

Name of Student                                                                                                            

Address of Student                                                                                                            

Name of contact in case of accident                                                                               

Contact phone in case of accident                                                                                   

Details of person to be insured

Premium calculation, which include all stamp duties are covered as part of the annual membership fee.

Premium fee per student                           $80.00

Period of cover               /        /              to                /       /

Declaration by the Applicant

I acknowledge:

1.        that I am authorised to complete this application and arrange the insurance contract on behalf of all the insured persons.

2. that if the applicant is accepted, the insurance cover will be subject to the terms and conditions as set out in the ‘Contract of Insurance’ or as otherwise specified varied by the insurer, in writing and agreed to by its members.

 Your duty of disclosure.  Before entering into a contract of general insurance with an insurer, you have a duty under the ‘Insurance Contract Act’ 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer’s decision whether to accept the risk or the insurance and, if so on what terms.  You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance.  Your duty however does not require disclosure of matter:  (a) that diminishes the risk to be undertaken by the insurer, (b) that is common knowledge; (c) that your insurer knows or, in the ordinary course of his business, ought to know; (d) as to which compliance with your duty is waived by the insurer.

 Non-disclosure.  If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce his liability under the contract in respect of a claim or may cancel the contract.  If your non-disclosure is fraudulent, the insurer may also have the option of voiding the contract from its beginning.

 I _____________________________ declare that the information supplied in this application form is true and correct in every particular and acknowledge that the insurer will rely on this information in deciding whether to give cover, and on what term.

 In accordance with the ‘Insurance Act (1984)’ Riai Aikido gives notice that this contract is effected under the authority given to Riai Aikido by the insurer ‘Sports Cover’ and Riai Aikido has effected the contract as the Insured of the named insurer on behalf of its students.

Signed by _____________________________  signed by ______________________

                        Being an authorised member of Riai Aikido                        Student to be covered by contract

Date:       /     /