Safe11 Sports Insurance
Safe11 Fussballer Versicherung ist eine Marke von
'WL Transparent' Finanzierungs- und Vermögensberatung GmbH
Walter Lenz Versicherungen
Korneuburger Str. 13-15, Stg. 1/7
2103 Langenzersdorf
Österreich

Tel.: +43 1 534 78 - 45 | Fax: +43 1 534 78 - 36 | office@safe11.at | www.safe11.at
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Safe11
Safe11
Sports 
 Insurance


We insure
your risk of injury!


Application


Application


Insurance application & medical examination form for sport disability insurance for professional athletes.



The filling in and sending of this suggestion binds neither the applicant nor the insurer to enter into an insurance contract. Every question must be answered fully and correctly.

+     Personal information
First name(s)


Surname


Street


Postal code


City


Telephone number


E-mail address


Your date of birth   [DD.MM.YYYY]


Club


League


Country (you play in)



Position


Your contract with your club ends on   [DD.MM.YYYY]
Corresponds to the insurance period


+     Sickness pay
Request insurance coverage



Insured risk

       100% continued salary payment from the 43rd day.

       Staggered continued salary payment:
  • From the 43rd day: 33.3% of the coverage
  • From the 61st day: 66.6% of the coverage
  • From the 91st day: 100% of the coverage

Coverage   [max. your net basic salary WITHOUT decimals and commas]


This amount is per:  
         



+     Disability
Request insurance coverage



Incl. accidental death   [in same amount as the coverage]



Coverage   [max. 4 times your net yearly salary WITHOUT decimals and commas]




+     Payment information
Payment method


Authorisation to collect the claim via SEPA Direct Debit
I authorise the named payment recipient to collect payments from my account through SEPA Direct Debit. I also instruct my/our bank to honour the SEPA Direct Debit requests to my/our account from the named payment recipient. I can reclaim the debited amount within eight weeks starting from the day it was debited. The terms agreed with my bank apply.
The direct debits will be activated at the due dates, which are explicitly named in the insurance contract. You can also find the amounts to be debited there.
PAYMENT RECIPIENT:
SCHUNCK GROUP Austria GmbH
1020 Wien, Handelskai 388/5/6. Stock
Gläubigeridentifikationsnummer / Creditor-ID:
AT03ZZZ00000028691

Name of the payer/account holder   [only with SEPA Direct Debit mandate]


Address of the payer/account holder   [only with SEPA Direct Debit mandate]


Name of bank of the payer/account holder [only with SEPA Direct Debit mandate]


IBAN of the payer/account holder [only with SEPA Direct Debit mandate]


BIC of the payer/account holder [only with SEPA Direct Debit mandate]


Payment interval sickness pay insurance
                 

Payment interval disability insurance
                 

+     Health questions
Are you currently free of injuries and/or illnesses and are you playing for your team?
      

Please state the number of games that you have missed and/or the amount of time during which you were disabled due to injury or illness in the last three years.   [Year / Number of missed games or amount of time / Suffered injuries or illnesses]


Please state the name and address of your general practice doctor.


Are you in good health, and was this true for the last 12 months? If NO, please provide details.
      


Have you visited a doctor in the last 2 years (excluding your club doctor)? If YES, please provide the details and the dates.
      


Is your eyesight hindered in any way or have you suffered eye illness or problems in the last 5 years? If YES, please provide details.
      


Is your hearing hindered in any way or have you suffered ear illness or problems in the last 5 years? If YES, please provide details.
      


Do you take any other medication/drugs than those prescribed by a doctor?
      

What is your average daily consumption of alcoholic beverages (a unit of alcohol is a glass of wine or spirits or 300 ml beer, lager or apple wine)?   [Units]


Have you visited a doctor or hospital for health complaints or a severe illness in the last 5 years? If YES, please provide details.
      


Have you had an surgery in the last 5 years or were you involved in any kind of accident? If YES, please provide details and dates.
      


Do you have a reason to believe that you will require a medical or surgical intervention in the near future? If YES, please provide details.
      


Are you currently insured against accident or illness? If YES, please state the name of the insurer and the insured items below.
      


Have you received benefits related to accident or illness? Please state the type of benefit, amount, name of company or underwriter in every case.
      


Were you ever rejected for a life insurance or accident insurance or private health insurance or accepted with special conditions? If YES, please provide detailed information (if you are co-insured through a group insurance, please ask).
      


Has a life insurance or invalidity insurance ever been terminated or rejected, or its extension postponed or suspended? If YES, please provide details.
      


Do you play any sports professionally, other than the one that is your primary profession? If YES, please provide details.
      


Please state the expiration date and the scope and framework of the work contract that is to be covered by this insurance contract (e.g. duration, yearly salary, continued salary payment).


+     Show health questions
Are you currently free of injuries and/or illnesses and are you playing for your team?


Please state the number of games that you have missed and/or the amount of time during which you were disabled due to injury or illness in the last three years.   [Year / Number of missed games or amount of time / Suffered injuries or illnesses]


Please state the name and address of your general practice doctor.


Are you in good health, and was this true for the last 12 months? If NO, please provide details.



Have you visited a doctor in the last 2 years (excluding your club doctor)? If YES, please provide the details and the dates.



Is your eyesight hindered in any way or have you suffered eye illness or problems in the last 5 years? If YES, please provide details.



Is your hearing hindered in any way or have you suffered ear illness or problems in the last 5 years? If YES, please provide details.



Do you take any other medication/drugs than those prescribed by a doctor?


What is your average daily consumption of alcoholic beverages (a unit of alcohol is a glass of wine or spirits or 300 ml beer, lager or apple wine)?   [Maßeinheiten]


Have you visited a doctor or hospital for health complaints or a severe illness in the last 5 years? If YES, please provide details.



Have you had an surgery in the last 5 years or were you involved in any kind of accident? If YES, please provide details and dates.



Do you have a reason to believe that you will require a medical or surgical intervention in the near future? If YES, please provide details.



Are you currently insured against accident or illness? If YES, please state the name of the insurer and the insured items below.



Have you received benefits related to accident or illness? Please state the type of benefit, amount, name of company or underwriter in every case.



Were you ever rejected for a life insurance or accident insurance or private health insurance or accepted with special conditions? If YES, please provide detailed information (if you are co-insured through a group insurance, please ask).



Has a life insurance or invalidity insurance ever been terminated or rejected, or its extension postponed or suspended? If YES, please provide details.



Do you play any sports professionally, other than the one that is your primary profession? If YES, please provide details.



Please state the expiration date and the scope and framework of the work contract that is to be covered by this insurance contract (e.g. duration, yearly salary, continued salary payment).


Health questions
Are you currently free of injuries and/or illnesses and are you playing for your team?


Please state the number of games that you have missed and/or the amount of time during which you were disabled due to injury or illness in the last three years.   [Year / Number of missed games or amount of time / Suffered injuries or illnesses]


Please state the name and address of your general practice doctor.


Are you in good health, and was this true for the last 12 months? If NO, please provide details.



Have you visited a doctor in the last 2 years (excluding your club doctor)? If YES, please provide the details and the dates.



Is your eyesight hindered in any way or have you suffered eye illness or problems in the last 5 years? If YES, please provide details.



Is your hearing hindered in any way or have you suffered ear illness or problems in the last 5 years? If YES, please provide details.



Do you take any other medication/drugs than those prescribed by a doctor?


What is your average daily consumption of alcoholic beverages (a unit of alcohol is a glass of wine or spirits or 300 ml beer, lager or apple wine)?   [Maßeinheiten]


Have you visited a doctor or hospital for health complaints or a severe illness in the last 5 years? If YES, please provide details.



Have you had an surgery in the last 5 years or were you involved in any kind of accident? If YES, please provide details and dates.



Do you have a reason to believe that you will require a medical or surgical intervention in the near future? If YES, please provide details.



Are you currently insured against accident or illness? If YES, please state the name of the insurer and the insured items below.



Have you received benefits related to accident or illness? Please state the type of benefit, amount, name of company or underwriter in every case.



Were you ever rejected for a life insurance or accident insurance or private health insurance or accepted with special conditions? If YES, please provide detailed information (if you are co-insured through a group insurance, please ask).



Has a life insurance or invalidity insurance ever been terminated or rejected, or its extension postponed or suspended? If YES, please provide details.



Do you play any sports professionally, other than the one that is your primary profession? If YES, please provide details.



Please state the expiration date and the scope and framework of the work contract that is to be covered by this insurance contract (e.g. duration, yearly salary, continued salary payment).