Insurance Application

Australian Working Adventures

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SECUTIVE WORK AND TRAVEL
INSURANCE APPLICATION FORM

Australian Working Adventures / Farmtrack is pleased to work with Secutive, and American based Insurance broker who provide a Work and Travel Insurance package that meets the needs of rural and outback farm workers.

You can Apply for this here.
This insurance is priced at $3 per day. The minimum period is 15 days. AUD $45
There is summary of the coverage at the bottom of this page.

application form (click here)

SECUTIVE INSURANCE
APPLICATION FORM
(please note you must complete all fields / answer all questions for the form to submit)

1. PERSONAL INFORMATION

* Indicates required field

Name *

First

Last

Email *

Mobile Number (Australian) *

Mobile number (other) *

Nationality and passport number *

Date of birth (format DD/MMM/YYYY) *

Home address (include country) *

2. MEDICAL INFORMATION

Are you a smoker ? *

Yes - smoker No

Do you have up to date Anti-Tetanus vaccination ? *

YES - tetanus vaccination is up to date NO

Do you have any physical conditions / impairments ? *

Yes, I have physical impairments No

Do you have any medical conditions under treatment / take any medications ? *

Yes (please explain in the box below) No

do you have any dietary conditions / requirements ? *

Yes - (please explain in the box below) Option 1 No

Please add any explanatory notes here *

3. INSURANCE REQUIREMENTS

Please insert dates in the format (dd/mmm/yyyy)
The minimum period for this insurance is 15 days.
The cost is $3 AUD per day.

THE START DATE SHOULD BE TODAY, THE DAY YOU DEPART FOR AUSTRALIA, OR THE DAY THAT YOU START ACTIVITIES AT THE TRAINING FARM.

Requested start date (can be today but not in the past) *

End date of Insurance (minimum 14 days after the startdate above) *

4. DECLARATION

I AGREE THAT A CHARGE OF $3 PER DAY WILL BE MADE FOR THIS INSURANCE.
I CONFIRM THAT I HAVE BEEN PROVIDED PRODUCT INFORMATION ABOUT THIS INSURANCE OFFER AND HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS TO MY SATISFACTION
I UNDERSTAND THAT MY PAYMENT FOR THIS INSURANCE WILL BE TAKEN VIA ON ONLINE PAYMENT LINK OR FROM THE PAYMENT DETAILS I PROVIDE BELOW.
I UNDERSTAND THAT INSURANCE COVER WILL NOT BE IN PLACE UNTIL PAYMENT HAS BEEN RECEIVED.
I UNDERSTAND THAT I WILL BE PROVIDED WITH A CONFIRMATION EMAIL TO CONFIRM MY INSURANCE COVER.

i CONFIRM AND ACKNOWLEDGE THE STATEMENTS IN THE DECLARATION ABOVE. *

YES - I CONFIRM NO ( INSURANCE WILL NOT BE PUT IN PLACE)

5. PAYMENT
We will respond to this application with an invoice and a payment link.
Alternatively you may pay us by direct transfer, over the phone or by inserting card details below.
You may indicate your preference below.
The policy details and certificate will be sent to your email once the application has been completed and payment has been received.

PAYMENT METHOD *

Long card number *

card holder name *

card expiry date *

CCV (last 3 numbers or back of card) *

SUBMIT MY INSURANCE APPLICATION

SUMMARY OF INSURANCE COVER (CLICK HERE)

BOOKINGS & ENQUIRIES
+61 (0)415 508135
[email protected]

MAIN OFFICE
+61 (0)721 118473
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