ISKA Martial Arts Insurance Package

APPLY FOR THE ISKA SPECIAL GROUP PACKAGE

CLUB INSURANCE
Please fill in all the mandatory fields as these are required by the insurer

THIS FORM IS FOR OUR PUBLIC LIABILITY PACKAGE
We can arrange Contents / Property, Events and Travel as well

We are not a Broker, but have authorisisation to offer our exclusive group policy to members. This arrangement provides you with group discounted insurance policies for your club.

SELECT THE TYPE OF INSURANCE YOU REQUIRE

Contact Name

First NameLast Name

Insured Business Name - School / Legal Trading Entity:

Trading As Name

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

Commence Date

Date

Member Number

How many student/member numbers?

Email

example@example.com

Mobile

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?

How many individual people train at your facility over the year ?

OVER THE YEAR

You can nominate when your Insurance to start, but will renew on a fixed date

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
vi. I/we understand that no insurance is in force until such time as our invoice has been paid.

Signature

Name

FULL NAMEDATED

Once your application has been approved ISKA will invoice you directly as part of your Membership/ Insurance and a Certifcate will be issued by the Broker

CONTACT FOR FUTHER INFORMATION

Jonathan Gleeson OAM | Managing Director
National Sport Karate Australia & International Sport Karate Association Australia Inc
M: 0401514902 E: jonathan@iska.com.au W: iska.com.au

Form Name - Leads Source (Hidden Field)

* For Zoho administration purposes