2026 Insurance Form

Name of your School / Academy / Club

Name of authorized person to complete this form

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (00) 00000000.

Email

example@example.com

Enter your KWA Membership Number

What is the current number of student members in your organization?

Enter your 2025-2026 Insurance Premium Cost $

List the disciplines / styles that are taught by your organization

Insurance Claims History - has your organization made any claims in the past 5 years (since May 2021)?

If your organization made claim/s since June 2021 - please detail 1) What happened leading to the claim/s 2) Cost of the claim 3)Were costs recovered from a third party?

Do you teach any of the following?

The core insurance for all organizations is Public and Products Liability. Would you like an optional quote for student accident (personal injury) cover? All clubs that teach Combat will be provided the optional quote - it is highly recommended that such cover be taken in the interests of your club members.

Disclaimer & Acknowledgement

By completing and submitting this survey, you acknowledge and agree that:

KungFu Wushu Australia (KWA / and its representatives) is acting in a facilitative capacity only, assisting your club in identifying and obtaining suitable insurance coverage. We are not a licensed insurance broker or financial adviser, and nothing in this process constitutes formal insurance or financial advice.

The information collected will be passed to a relevant insurer or broker who will provide a formal recommendation. The final decision regarding any insurance policy rests solely with your club. (For the avoidance of doubt: Public and Products Liability Insurance is compulsory for all members, who also have the option of additional Personal Injury/Accident cover)

KungFu Wushu Australia (KWA / and its representatives) accepts no liability for any loss, claim, or damage arising from the use of information provided through this survey, or from any insurance policy arranged as a result of this process.

Name of signatory

Date signed

Signature