MAAIS Insurance Application

Martial Arts Insurance Quote Application

Martial Arts Australia Insurance Services Pty Ltd ABN: 31 632 785 329 AFS Representative No: 001283262 of United Insurance Group Pty Ltd ABN 31 131 564 522 AFSL 327131
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 AccidentPREMIUM PACKAGE 2- 20mil (PL) & (PI) + Player AccidentMANAGEMENT LIABILITY- 1 millionEVENT ONLY - For one or more Fight Shows or Tournaments per yearINSURANCE HEALTH CHECK - Not Sure What You Need - Want To Discuss
Client History*

New ClientExisting ClientPrevious Client
Contact Name*

First NameLast Name
Insured Business Name - School / Legal Trading Entity:*
Trading As Name*
Business Type*
ABN / ACN
Type number for either - Australian Business Number or Australian Company Name
Additional Persons / Instructors Names:
*Note all instructors are covered under the insurance and are not required to be named and listed. Instructors listed on policy at no charge, to be MAA Certified there is a cost with Membership
Add these instructors to:

PolicyMembershipBoth
Do you require a landlord to be listed on the policy? Add below or type N/A:
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. Its Australia wide cover so you don't have to list all locations.*

Street Address

Street Address Line 2

SuburbState

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.

YESNO

Past Claims Information*

	YES	NO
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 or BJJPurple or higher?Strength and Conditioning CoachInhouse Instructor's CourseAMACS Instructor CourseWorking with Children CheckCert IV PT Fitness (or higher)Police CheckCert III Gym / Fitness InstructorFirst Aid CertificateAssociation Coaching Accredited
Provide further qualifications / workplace related if appropriate. If you don't fit the Belt criteria because your system doesn't use them, (like Tai Chi / Muay Thai) describe others ways you are qualified to teach your art / style.

Operation Details*

	YES	NO
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, 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	SA	WA	NT	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.
Signature*

Clear
Name*

FULL NAMEDATED
There are a number of steps to arrange insurance cover for you, but it can be done the same day. 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 'bind your policy' (it will start) and create the rest of documents (invoice / certificate of currency etc). You will have a short period to pay the invoice, or pay via 10 monthly installments.

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

This form will be sent to: Martial Arts Australia Insurance Services
You can discuss details via Email: gslater@martialartsinsurance.com.au
Or - P: 03 8201 9908 URGENT: 0451 331 958 (Text 24/7)

This is not for Insurance payments you will be invoiced separately. This is for your Martial Arts Australia Professional Membership, which provides numerous benefits such as - automatically receive a special insurance discount, the same on billing, software, websites, courses, events and free advertising, graphics packs, instructor accreditation, business tools, industry magazines etc. Select any membership level below.

MAA BRONZE MEMBERSHIPInstructor Accreditation Club Forms & Waivers MAA Logo for Club Use

$125.00AUD Quantity

MAA SILVER MEMBERSHIPPrinted Membership Pack Discounted Services Tier 2 Club Listing Priority - Tier 2

$195.00AUD Quantity

MAA GOLD MEMBERSHIP5x Instructor Accreditation Senior/Master Accreditation Discount Club Listings - Top Priority Mentoring/Consultancy Discount

$295.00AUD Quantity

Total

$0.00AUD

Credit Card Details are only for Martial Arts Australia's Membership ONLY! INSURANCE will be invoiced separately once approved.
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Form Name - Leads Source (Hidden Field)
* For Zoho administration purposes
Should be Empty:

Martial Arts Insurance Quote Application