MAAIS Insurance Application

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

Client History

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:

Do you require a landlord to be listed on the policy? Add below or type N/A:

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.

Past Claims Information

Rows	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

Rows	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?

PLEASE PROVIDE MORE INFO: 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. You will need to add specific duration of training, any coaching courses and other validation, to meet the industry standards as a coach in your art.

YOU MAY ALSO BE ASKED TO PROVIDE YOUR WAIVER, INCIDENT REPORT & RISK MANAGEMENT DOCUMENTS IF YOU DON'T HAVE THESE DOCUMENTS, THEY CAN BE PROVIDED FOR YOU, THROUGH MAA

Operation Details

Rows	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-

Rows	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

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.

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)

NOT A MEMBER OF MARTIALA RTS AUSTRALIA? NO PROBLEM DO IT RIGHT NOW! Martial Arts Australia Peak Industry Body Offer Their Professional Membership BEENFITS: insurance discount, the same on billing, software, websites, courses, events and free advertising, graphics packs, instructor accreditation, business tools, industry magazines, business consulting etc. Select any membership level below.

MAA SILVER MEMBERSHIP (digital pack only)

Includes -

2 x Instructor Accreditations (pdf certificate)

Directory Listing

Marketing Graphic Banner Pack

Risk Management Pack

Industry Publication

Use of MAA logo on your site

Discounts on:

Club Insurance

Travel Insurance

Club Software

Billing – Student Fee Collect

Website Design & Hosting

Business Coaching

Training Courses:

AMACS Level 1 – x 1 person $50 (Value $250)

AMACS Level 1 – x unlimited $150 (Value $150)

Other AMACS Levels 2 & 3 POA

Insurance Risk Management Course x 1 $50 (Value $245)

$150.00 AUD Quantity

MAA GOLD MEMBERSHIP (posted pack)

Includes-

5 x Instructor Accreditations (Digital & Print pack certificates, cards, badges)

4-5 Star Instructor Rating

Directory Listing

Marketing Graphic Banner Pack

Risk Management Pack

Industry Publication

Use of MAA logo on your site

Discounts on:

Club Insurance

Travel Insurance

Club Software

Billing – Student Fee Collect

Website Design & Hosting

Business Coaching

Training Courses:

AMACS Level 1 – x 1 person $0 (Value $295)

AMACS Level 1 – x unlimited $100 (Value $200)

Other AMACS Levels 2 & 3 POA

Insurance Risk Management Course x 1 $0 (Value $295)

Insurance Risk Management Course x unlimited $50 (Value $245)

$295.00 AUD Quantity

ADD ON - ADDITIONAL INSTRUCTOR/S

Add additional instructors to your Membership

$25.00 AUD Quantity

Total

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

Martial Arts Insurance Quote Application