Motorsport Affiliate Clubs Insurance

General Information

Name of Organisation affiliated with AASA*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the organisation Incorporated?*

Are you a GST registered business?*

ABN Number*

If you claim less than 100% of the GST in your premium as an Input Tax Credit (ITC) please advise?*

eg, 90%

Contact Name*

Role / Position*

Mobile*

Email*

Website*

Period of Insurance required

From*

To*

Coverage Options

Association Liability (Directors & Officers Liability)
Annual premium based on revenue
LIMIT OF INDEMNITY - $5,000,000
PREMIUM Revenue up to 100k - $467.50
PREMIUM Revenue up to 101k to $250k - $687.50
PREMIUM Revenue up to 251k to $500k - $1,182.50

Public and Products Liability - $10,000,000
LIMIT OF INDEMNITY - $10,000,000
PREMIUM 1 to 500 members - $687.50
PREMIUM 501 to 1,000 members - $1,237.50
PREMIUM 1,001 to 2,500 members - $1,787.50

Public and Products Liability - $20,000,000
LIMIT OF INDEMNITY - $20,000,000
PREMIUM 1 to 500 members - $818.75
PREMIUM 501 to 1,000 members - $1,500.00
PREMIUM 1,001 to 2,500 members - $2,181.25

Note:
Premiums are inclusive of all fees and charges.
Premiums are subject to change.
Stamp Duty Rates vary between the states.

Coverage Required

Please select the coverage required*

Association Liability (Directors & Officers Liability) - $5,000,000
Public and Products Liability - $10,000,000
Public and Products Liability - $20,000,000

Underwriting Information

Activities undertaken*

Organisation Numbers*

Membership Numbers	Membership Sales	Sponsorship Fees	Event Fees	Fundraising / Donations	Employee Numbers

Please complete the table below with respect to club events and/or events promoted, managed and/or organises e.g. ride days, car shows, touring events, social events, children’s parties etc.:*

Event Type	Event Description	Estimated no. of events for the year	Average no. of people attending event	Maximum no. of people attending event

Are all participants required to sign a “disclaimer” to “release and indemnify” the organisation in regards to acknowledgment of risks, injury and obligations?*

Do you assume Liability under contract?*