Microsoft Word - 2018-19_Basketball ACT Personal Injury Claim Form_1.pdf

Okay, I need to create a concise summary of this basketball insurance document. Let me start by reading through the content carefully.

First, the document is the Personal Injury Claim Form for the Australian Capital Territory Basketball ACT Insurance Program. The insurance broker is Willis Australia Limited, with their contact details. The policy number and claim number fields are there, and the claim forms must be sent to Corporate Services Network via GPO Box, phone, fax, or email.

Then there's a summary of the insurance cover on page 2. The benefits include Death & Permanent Disablement, which pays $100k for members 18-65 and $20k for under 18 or over 65. Non-Medicare Medical Expenses reimburse up to 75% of costs, with a max of $2k ($5k for volunteers), and 100% for ambulance. The Student Tutorial Costs cover up to 80% of home tuition costs, max $200 per week for 52 weeks. Domestic Help Benefit is similar, up to 80% of home help service costs, with a 7-day excess. Loss of Income is 100% of earnings for 52 weeks, max $250/week for members, $700 for volunteers. Funeral Benefit is an additional $10k.

Important Notes mention that the insurance is underwritten by Arch Underwriting. The summary is factual but not a full policy. The program started on 1 September 2020. V-Insurance facilitates it, but it's not a registered broker. They can't cover all losses, especially those related to Medicare. Members are advised to take private health insurance.

Then the How to Make a Claim section: the form must be completed, pages 4-6 filled out, signed declaration. For Loss of Income, pages 7 and 8 need employer or accountant info, payslips, and Tax File Number. For medical claims, the attending physician's statement is required. Attach itemized receipts, not just estimates. If private health fund covers treatment, include rebate advice. Note that Surgeons, Anaesthetists, etc., are not covered if partially Medicare. Treatment must be completed within 12 months.

Association/Club must confirm the injury occurred during a sanctioned activity. Once submitted, the claim is processed by Corporate Services Network, and reimbursement is direct to the bank account. Ongoing receipts can be submitted via them. Contact details are provided for inquiries.

I need to make sure the summary is detailed but concise, in English, without any markdown. Start directly with the content. Highlight the key benefits, the process, and the important notes. Mention the insurer, the broker, the contact info, the benefits sections, the conditions, and the steps to make a claim. Also note the limitations and the need for private health insurance.

Check for any specific terms or numbers that need to be included. Make sure not to add any extra information. Keep it straightforward, bullet points or short paragraphs. Avoid titles or introductions. Ensure all main points are covered: benefits, claim process, important notes about Medicare and private insurance, and the contact details for submission.

The Basketball ACT Insurance Program, facilitated by V-Insurance Group, provides financial support for members injured during sanctioned activities. Key benefits include:
- Death & Permanent Disablement: $100,000 for members aged 18–65, $20,000 for those under 18 or over 65.
- Non-Medicare Medical Expenses: Up to 75% of eligible costs (max $2,000/$5,000 for volunteers) with 100% coverage for ambulance. Excess applies: $0 for private health insurance holders, $50 otherwise. Expenses must occur within 12 months of injury.
- Student Tutorial Costs: 80% reimbursement of home tuition costs (max $200/week for 52 weeks).
- Domestic Help Benefit: 80% reimbursement of licensed home help services (max $200/week for 52 weeks), with a 7-day excess.
- Loss of Income: 100% of weekly earnings (max $250/$700 for volunteers) for 52 weeks, with a 7-day excess.
- Funeral Benefit: Up to $10,000 for funeral expenses if death is covered.

Important notes:
- Coverage excludes Medicare-covered services (e.g., surgeons, anaesthetists, X-rays) or those partially covered by Medicare.
- Members must complete the claim form, attach itemized receipts, and have their Association/Club confirm the injury occurred during a sanctioned activity.
- Claims are submitted to Corporate Services Network (GPO Box 4276, Sydney; contact details provided). Reimbursements are direct deposits into the insured’s nominated account.
- The program began on 1 September 2020 and is underwritten by Arch Underwriting.
- V-Insurance is not a registered broker; members are encouraged to take private health insurance for full coverage.

For claims, ensure pages 4–6 are fully completed, sign the Declaration, and include employer/employer’s details, payslips, and a Tax File Number Declaration. Medical claims require a physician’s statement. Ongoing receipts can be submitted via Corporate Services Network. Contact details: (02) 8599 8660 or 1300 945 547.