Personal Accident Weekly Benefit

Benefit Overview

The Flexible Insurance Options product overview can be found at the link below.
Please ensure that you have read this document thoroughly before apply for this additional cover.

FLEXIBLE INSURANCE OPTIONS OVERVEW →

Benefit Overview Declaration*

I declare that I have read the Flexible Insurance Options overview and fully understand all aspects of this insurance product

Personal Details

First Name*

Last Name*

Mobile*

Email*

Current Application

This benefit increase application can only be applied to one valid licence.

Licence Type*

Licence Number for this benefit to be applied*

Benefit Selection

The standard benefit provided is $900 per week. Please refer to the online insurance summary for additional details. This cover only applies for claims which occur at an AASA sanctioned event.

Please select the amount you would like this increased to:*

$1,100 per week (cost is $500)
$1,300 per week (cost is $750)
$1,500 per week (cost is $1,000)

Increase weekly benefits to $1,100*

Price: $ 500.00

Increase weekly benefits to $1,300*

Price: $ 750.00

Increase weekly benefits to $1,500*

Price: $ 1,000.00

Total

$ 0.00

Declaration*

I declare that all information provided for the purposes of this application is true and accurate to the best of my knowledge. I understand that in providing false or misleading information my licence may be suspended or cancelled, and I may not be afforded the coverage of the Personal Accident and Injury insurance provided under the AASA Insurance Scheme. I agree to comply with the AASA National Competition Rules at all times when participating in a AASA Sanctioned Event.

Credit Card*

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name