MAAIS Insurance Application

Martial Arts Insurance Quote Application

Martial Arts Australia Insurance Services Pty Ltd ABN: 31 632 785 329 AFSR No: 001283262 Authorised Representatives of Marsh Advantage Insurance Pty Ltd - AFSL: 238369
Please Note: The Insurer uses a number of elements to calculate your premium including member / class numbers and annual turnover. Fill in the form with what you feel is the appropriate information and we will call you to clarify anything extra we need.
SELECT THE TYPE OF INSURANCE YOU REQUIRE *

STANDARD PACKAGE 1- 10mil Public Liability (PL) 5mil Civil Liability (PI) STANDARD PACKAGE 2- 20mil Public Liability (PL) 5mil Civil Liability (PI) PREMIUM PACKAGE 1- 10mil (PL) & (PI) + Player Accident PREMIUM PACKAGE 2- 20mil (PL) & (PI) + Player Accident MANAGEMENT LIABILITY- 1 million BUSINESS PACK- Property / Contents / Business Interruption / Glass Breakage EVENT ONLY - For one or more Fight Shows or Tournaments per year INSURANCE HEALTH CHECK - Not Sure What You Need - Want To Discuss
Contact Name *

First Name Last Name
Insured Business Name - School / Legal Trading Entity: *
Additional Persons / Instructors Names to be listed on Policy:
*Note all instructors are covered and are not required to be named and listed.
More Entities? Interested Parties? Add them:
Remember to add Interested parties now to avoid processing fees later. *Updates and amendments to Certificate of Currencies such as interested parties, address may incur an additional administration processing fee of $25.00.
Email *
example@example.com
Website
Mobile *
Phone
School/Training Location *if more than one location, only add main school's address. *

Street Address

Street Address Line 2

Suburb State

Postal Code
Postal Address
Only required if different from School/Training location
Type of Business - *
Please select the Category Type that best describes your business.
NSW ONLY - Are you a small business eligible for the exemption from the requirement to pay NSW duty on certain types of insurance? If yes we deduct the stamp duty off the invoice.

YES NO

Past Claims Information *

YES

Are you aware of any insurance being declined or cancelled, application/proposal rejected, renewal refused, claim rejected, or special conditions or excess imposed by any insurer?

Are you aware of any claims made against you in the past 5 years?

Have you had an incident or accident which would be insured by the proposed insurance?

Are you aware of anyone having been charged with or convicted of any criminal offence (excluding traffic offences)?

Have you ever, either alone or jointly with others, been declared bankrupt or subject to any form of insolvency administration (e.g. liquidation or receivership)?

Training / Coaching Experience *

5 years and over

1 to 5 years

NEW

How many years experience does the Insured have?

How established is the Insured's Business?

What qualifications/checks do you hold that are relevant to the Insured Activities? *

Black belt/Purple sash or higher? Strength and Conditioning Coach Inhouse Instructor's Course Professional Affiliations Working with Children Check Certificate IV in Fitness (or higher) Police Check Gym / Fitness Instructor First Aid Certificate NSO Coaching Accredited

Operation Details *

YES

Does the Insured, including Employees and freelance coaches/instructors if engaging them, hold industry recognised qualifications and suitable experience that is/are relevant to The Business activities of the Insured?

Does the Insured use documented risk management procedures, incident report register, participant waivers, OHS/WHS policies and procedures?

If instructing at third party premises, does the Insured carry out an assessment to ensure the space is fit for purpose prior to any instructing?

Is the Insured's facility ever unsupervised by staff when open for use?

Does the Insured operate any warrior, ninja or parkour training or classes?

Does the Insured have a Creche?

How many individual people train at your facility?
How many classes do you run each week?
Do run Fight Shows or Tournament Circuits? YES / N0 - How Many PY?
Do you organise events open to non-members, tickets sold or does the total prize money exceed $5,000? YES / NO
Estimated yearly turnover is only required if you lease or own your training facility.
Date you require Insurance to Start *

How many Schools/Centres does the Insured own/operate? Insert the number of schools and the state they are located in-

NSW

QLD

VIC

TAS

ACT

Number of Schools

DECLARATION
I/We the undersigned duly authorised person(s) declare that:
i. I am/we are authorised by each of the Proposers to sign this Proposal Form; and
ii. the above statements are correct, true and complete; and
iii. no information material to this Proposal Form has been withheld; and
iv. I/we have read the important facts which you have put before me/us and I/we understand the advice given in relation to the duty of disclosure; and
v. I/we have diligently made all necessary and detailed enquiries in order to comply with the duty of disclosure; and
vi. I/we understand that no insurance is in force until such time as the insurer has confirmed acceptance of the proposed insurance; and
vii. I/We undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance; and
viii. I/we acknowledge that the Insurer relies on the information and representations in this Proposal Form and otherwise made by me/us in relation to this insurance.
Use your mouse to Sign your name

Clear
Name

FULL NAME DATED
This application form will be used to create a letter of offer for the nominated insurances you have selected. Upon your acceptance of this offer we will create the rest of documents (invoice / certificate of currency etc).

Payment Methods: Wait for the Broker / Insurer invoice to make payment (options apply).

Send all correspondence to: Martial Arts Australia Insurance Services
Postal: P.O Box 2057 Blackburn South VICTORIA 3130
DISCUSS - P: 03 8201 9908 URGENT: 0451 331 958 (Text 24/7)
National Office: 6 / 12 Henderson Road, Knoxfield VICTORIA
Should be Empty:

Martial Arts Insurance Quote Application