PROBUS TRavel InSURance For travel from 1 December 2013 to 30 november 2014

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Norah McCormick
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1 PROBUS Travel Insurance For travel from 1 December 2013 to 30 November 2014

2 PROBUS TRAVEL INSURANCE SUMMARY FOR TRAVEL BETWEEN 1 DECEMBER 2013 TO 30 NOVEMBER 2014 COVERED PERSON Any Probus club member and guest on authorised Probus Travel and/or Private Travel. AGE LIMITS 100 years (noting limitations below) GEOGRAPHICAL LIMITS Domestic and Worldwide COVERAGE All figures are in Australian dollars. All claims will be calculated in Australian dollars. Section 1 - Personal Accident Probus Travel Accidental Death - Limit $20,000 Permanent Loss of Use up to a maximum of $20,000 Private Travel Accidental Death - Limit $10,000 Permanent Loss of Use up to a maximum of $10,000 Section 2 - (A) Medical & Additional Expenses - Limit $100,000 Excess: $ Medicare gap exclusion applies. 2. The excess applies to each Covered Person. 3. The maximum sum insured payable for a Covered Person aged from 91 to 100 years is $5,000 (B) Cancellation & Curtailment Expenses - Limit $5,000 Excess - $200 Note: 1. The excess applies to each Covered Person. 2. For Covered Persons from 81 years of age there is no cover for cancellation/curtailment of a journey due to illness. 3. For Covered Persons from 91 years of age there is no cover for cancellation/curtailment of a journey. 4. Claims in relation to trips to Norfolk Island attract an excess of $500 per Covered Person. (C) Continuous Bed Confinement Daily Benefit - $60 (Limit 30 Days) (D) Trauma Counselling Daily Benefit - $500 (Limit $5,000) Section 3 - Loss of Deposit - Limit $5,000 Excess - $200 Note: 1. The excess applies to each Covered Person. 2. For Covered Persons from 81 years of age there is no cover for loss of deposits due to illness. 3. For Covered Persons from 91 years of age there is no cover for loss of deposits. 4. Claims in relation to trips to Norfolk Island attract an excess of $500 per Covered Person. Section 4 - Kidnap/Ransom & Extortion - Limit $100,000 per event 2

3 PROBUS TRAVEL INSURANCE SUMMARY FOR TRAVEL BETWEEN 1 DECEMBER 2013 TO 30 NOVEMBER 2014 Section 5 - (A) Baggage, Money & Documents Property - Limit $5,000 - limit any one item $1,500 Excess - $100 (B) Electronic Equipment - Limit $5,000 Excess - $250 (C) Deprivation of Baggage - Limit $2,000 (D) Money & Travel - Limit $1,000 Excess - $100 Section 6 - Personal Liability - Limit $5,000,000 Section 7 - Rental Vehicle Excess Waiver - Limit $3,000 (cover applies for domestic trips greater than 50 kms within Australia and New Zealand only) Section 8 - Hijack & Detention Daily Benefit $100 (Limit 60 Days) Legal Costs Limit $3,000 Section 9 - ACE Rescue (Emergency Assistance) - included Section 10 - Missed Transport Connection - Limit $5,000 Section 11 - Over Booked Flight - Limit $2,500 Section 12 - Political and Natural Disaster Evacuation - Limit $10,000 (aggregate $100,000) Section 13 - Search & Rescue Expenses - Limit $20,000 (aggregate $100,000) Pre-Existing Conditions Included Please read the section titled Pre-Existing Medical Conditions on page 5 for more information Insurer: ACE Insurance Limited ABN: Policy Number: 04PP Please note that this is a summary of the insurance coverage. Probus South Pacific Limited (ACN ) does not hold an Australian Financial Services Dealers Licence and cannot provide any recommendation or advice regarding cover. Terms, conditions, limitations and exclusions apply. Please refer to the Probus Travel Insurance Master Policy on the Probus website for full coverage terms available. 3

4 APPLICATION FORM Probus Club of: Applicant 1 (Please print clearly) Salutation Given Names Last Name Date of Birth Postal Address Suburb Postcode * Probus Club of: Are you Member or Guest? (please tick a box) Member Guest Probus Membership Card No*. *Please contact your club secretary or Probus South Pacific if you do not know your Probus Membership Card number Mr / / Mrs Ms Dr Other (please specify) Country Age State/ Town/City Phone ( ) *By providing an address, you agree to have all correspondence relating to this application sent to you by . Applicant 2 (Please print clearly) Salutation Given Names Last Name Date of Birth Postal Address Suburb Postcode * Are you Member or Guest? (please tick a box) Member Guest Probus Membership Card No*. *Please contact your club secretary or Probus South Pacific if you do not know your Probus Membership Card number Mr / / Mrs Ms Dr Other (please specify) Country Age State/ Town/City Phone ( ) *By providing an address, you agree to have all correspondence relating to this application sent to you by . 4

5 APPLICATION FORM Trip Information (Please tick one box) Probus Trip Private Trip Period of journey (Maximum 120 days*) days First travel date Last travel date / / / / *Please note that your trips starts when you leave your residential address and ends when you arrive back at your residential address in accordance with your travel dates. The maximum length of a trip is 120 days Destination # (Please tick one or more of the following) Australia India Norfolk Island USA / Canada Asia Africa Japan Middle East Pacific Islands South America Other (please specify) Bali New Zealand United Kingdom / Europe #Due to current sanctions coverage cannot be provided for travel to Cuba Probus Club Tour Organiser name (if applicable) Probus Club of: Probus Club Tour Organiser phone ( ) Pre-existing Medical Conditions The exclusions for pre-existing medical conditions on the Probus Travel Insurance policy has been waived. This means that all pre-existing conditions are covered, however, the following conditions still apply: 1. Each Covered Person(s) must obtain a letter from their doctor advising that they are fit to travel. Each Covered Person(s) must obtain this letter before applying for this travel insurance. This letter must be dated no more than 21 days BEFORE the date of this travel insurance application and MUST be provided with this application. 2. The Covered Person(s) cannot travel solely for the intention of having treatment for an existing medical condition. 3. The policy will not cover expenses incurred for any medication for a condition commenced prior to the commencement of the journey which such medication the Covered Person(s) has been advised to continue during travel. Cancellation & Claims The Travel Insurance fee may only be refunded within 14 days of the application and payment being processed by Probus South Pacific Limited. Covered Persons entitled to make a claim under the policy must give ACE Insurance Limited written notice of any occurrence which is likely to result in a claim within 30 days or as soon as practicable after the date of occurrence. 5

6 Declaration Statement I/We the undersigned agree that one of the applicants taking out the Probus Travel Insurance is a current Probus club member. I/We the undersigned have read the Probus Travel Insurance Important Information Booklet. I/We understand that the documentation issued to me/us by Probus South Pacific Limited in relation to the Probus Travel Insurance has been prepared by Probus South Pacific Limited for general information only. For information about the actual policy terms and conditions I/we will refer to the Probus Travel Insurance Master Policy referred to herein as the Master Policy which can be viewed on the Probus South Pacific Limited website at www. probussouthpacific.org or Probus South Pacific Limited will provide me/us with a hard copy, should I/we request them to do so. I/We understand that the Master Policy should be read before a decision is made to purchase this travel insurance. I/We understand that Probus South Pacific Limited does not hold an Australian Financial Services License and does not act on behalf of ACE Insurance Limited. Probus South Pacific Limited cannot provide any recommendation or advice regarding cover. I/We understand that the information provided by me/us will be used in accordance with the Privacy Act 1988 in Australia and the Privacy Act 1993 in New Zealand. Probus South Pacific Limited s Privacy Policy can be viewed at If after I/we have read the Policy Document and if I/we still have any questions, I/we can contact the Insurance Brokers at AON Risk Services on or This Declaration Statement must be signed by Applicant 1 Full Name Signature Date This Declaration Statement must be signed by Applicant 2 (if applicable) Full Name Signature Date Credit Card Authority Form Card Type: (Please tick one) MasterCard Card Number: Expiry Date: / VISA / / / Amount AUD$. 00 Please contact Probus South Pacific for current price. Name of Card Holder I authorise Probus South Pacific Limited to debit my credit card with the amount shown above. I understand that all payments debited to my credit card will be in Australian Dollars. This form must be signed by the Card Holder Signature 6

7 CHECKLIST Before sending your application for Probus Travel Insurance, please confirm: Each applicant has read and signed the Declaration Statement on page 6; A fit to travel report for each applicant is attached to this application. Please make sure you keep a copy of the fit to travel report for each applicant for your records If paying by cheque, that the cheque is made payable to Probus South Pacific Limited; If paying by credit card, that the cardholder has completed and signed the credit card authority on this page. With Probus South Pacific for current prices as prices are subject to change without notice. Please forward your completed application form and fit to travel reports by 1. to travelinsurance@probussouthpacific.org OR 2. Fax to (02) OR 3. By post to Probus South Pacific Limited PO Box 1294 Parramatta NSW 2124 ACE ASSISTANCE If you require assistance anywhere in the world, contact the local telephone operator and ask for a reverse charge call to ACE Assistance on Country City Number Policy Number: 04PP Probus South Pacific Limited ABN: ACN: PO BOX 1294 Parramatta AUSTRALIA NSW 2124 Phone: New Zealand: Fax: travelinsurance@probussouthpacific.org 7

Corporate Travel. Your Details: Period of insurance. Claims History. Full Name of the Insured. Address. ABN No. Nature of Business

Corporate Travel. Your Details: Period of insurance. Claims History. Full Name of the Insured. Address. ABN No. Nature of Business HOW TO FILL OUT THIS FORM Please fill out every question neatly and clearly. This will assist us in evaluating your application and if we are unable to read the information you have given us, we may not