Wellness Insurance Application (Fitness, Sports++)

Wellness Liability Insurance Review & Quote Application

Wellness Facilities, Recovery Centres, Gyms - Health Clubs - PT Studios - Yoga / Pilates Studios - Martial Arts Clubs
Please Note: The Insurer uses a number of elements to calculate your premium including member / class numbers and annual turnover. They also take into account the types of activities and equipment used in your facility.

Please fill in the form the best you can and we will review with you to make sure we fully understand your operation and can assist you with risk management to further reduce your insurance premium.
STANDARD PACKAGE 1- 10mil Public Liability (PL) 5mil Civil Liability (PI)STANDARD PACKAGE 2- 20mil Public Liability (PL) 5mil Civil Liability (PI)MANAGEMENT LIABILITY- 1 millionBUSINESS PACK- Property / Contents / Business Interruption / Glass BreakageCYBER INSURANCETRAVEL INSURANCE
Contact Name*

First NameLast Name
Insured Business Name - Gym / Studio / Club (Legal Trading Entity):*
Business Type*
ABN / ACN
Type number for either - Australian Business Number or Australian Company Name
More Entities? Interested Parties? Add them here:
Email*
example@example.com
Website
Mobile*
Phone
Club / Gym Location *if more than one location, only add main school's address.*

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.
YESNO

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?

Black Belt or 5yrs+ MA trainingStrength & Conditioning CoachProfessional AffiliationsPilates - teacher trainer courseCert IV in Fitness (or higher)Cert III+ Sports CoachYoga - teacher trainer coursePolice CheckWorking with Children CheckFirst Aid Certificate

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?
Estimated yearly turnover is only required if you lease or own your training facility.*
Date you require Insurance to Start*

How many Gyms/Centres/Clubs/Studios 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 Gyms

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
Name

FULL NAMEDATED
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: Gym Insurance Brokers a division of
Martial Arts Australia Insurance Services
ABN: 31 632 785 329 AFS Representative No: 001283262
of United Insurance Group Pty Ltd ABN 31 131 564 522 AFSL 327131

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
Form Name - Leads Source
*For zoho Administration purposes only
Should be Empty:

Wellness Liability Insurance Review & Quote Application