Wellness Centre Risk Assessment & Insurance Quote Form

This form is to get to know you better, explain what we do and how we can assist you with this FREE Business Risk Management Review.

Your information helps us to provide optional business solutions that can reduce operational costs, better protect your facility and make it more profitable.

As Business Consultants, Publishers and Insurance Brokers we are perfectly positioned to share industry insights, resources and tools to further build and protect your business.

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

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

Let us know how we can help you!

Rows	YES	NO
Risk Management - Unsupervised activities, wet / sauna / rehab, cryo chambers etc
Allied health (massage, naturaphy etc), Longivity doctors - (pathology / blood works)
Group fitness / martial arts classes (other than Tai Chi / Qi Qong), Bouldering, Rock Climbing, CrossFit, Altitude Training
Insurance gaps in cover, reduce risk get cheaper premiums, split policies greater business proetection. How to protect against a personal injury claim. What to do in the event of a claim.
Are staff / Contractors over stepping their expertise in providing coaching / health advice or do they need to upskill or leave to the actual specialist. Access the team's qualifications to make sure there isn't any PI insurance exposures.

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

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?

List Your Group Fitness Classes and Services (creche, cafe, sauna, pool etc)

SELECT THE TYPE OF INSURANCE FOR A QUOTE

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)?

How many individual people train at your facility?

How many classes do you run each week?

Estimated yearly turnover for 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 FOR INSURANCE
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 free business consultancy plan
and a letter of offer for the nominated insurances you have selected.
Upon your acceptance of this offer we will create the rest of documents and timeline to provide your review and insurance quote.

Insurance Quotes will come from '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

Wellness World Media - Fit Multimedia - Martial Arts Australia
As one network, will provide your Free Business Consultancy & Media Support

Your Personal Consultant & Broker
DISCUSS - P: 03 8201 9908 Graham Slater: 0419 569 565
National Office: 6 / 12 Henderson Road, Knoxfield VICTORIA

Form Name - Leads Source

*For zoho Administration purposes only