DRAFT 2018 Club Change of Insurance Request

2019 Club Change of Insurance Request

Thank you for choosing to affiliate with Gymnastics Victoria (GV) and Gymnastics Australia (GA) in 2019.

This form is to be used by clubs who have already completed the 2019 Club Affiliation Form.

Only complete this form to change your insurance arrangements in 2019 if you have already submitted the 2019 Club Affiliation Form to Gymnastics Victoria.

The cost of the Gymnastics national insurance program is $1,078.00 for 2019.

Club Name *
Details of person completing this form *

First Name Last Name
Phone Number *
Phone number
Email *
E-mail
What change are you making *

Change to the gymnastics national insurance program Change away to a different insurance program

2019 Club Change of Insurance Request

Insurance

Gymnastics Australia's National Risk Protection Program (the Program) provides four key insurance covers, outlined at the link below.

The Program utilises the buying power of hundreds of affiliated gymnastics clubs across Australia. This has resulted in considerable savings and enhanced coverage for clubs who purchase these policies.

1. Personal Accident Insurance:	This is Standard Insurance Cover available to registered club members. It covers: - Non-Medicare costs; - Loss of Income; and - Capital Benefits associated with personal injuries sustained during official gymnastics club activities.
The Personal Accident Insurance premium is included within the membership fees for all members. As per the National Affiliation Standards, the club must register all participants in accordance with the National Membership Database Policy to ensure Insurance cover can be confirmed.
2. General Liability Insurance:	This policy is available to affiliated clubs. It covers legal liability to pay compensation arising from Personal Injury, Property Damage and Advertising Liability to third parties for breaching its duty of care (negligence).
3. Professional Indemnity Insurance:	This policy is available to affiliated clubs. It covers certain costs associated with a claim against the club, its members, employees and officers for a breach of professional duty in the conduct of the club's business.
4. Management Liability Insurance:	This policy is available to affiliated clubs. It covers a range of areas including legal action against the committee or directors of the club for wrongful acts or omissions.

The National Risk Protection Program is administered by Marsh Advantage Insurance (Marsh). For a simple summary of each policy and other important information, terms and conditions, please visit the Marsh website at https://www.marshadvantage.com.au/partner-group/gymnastics/welcome.html.

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Club Liability Insurance Covers (2, 3 & 4 above) Do you wish to purchase General Liability, Professional Indemnity and Management Liability Insurance for your club through the Program? *

Yes. No.
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2019 Club Change of Insurance Request

Insurance (cont'd)

Insurance: Opt Out

The Club is not purchasing Club Liability Insurance Covers through the Gymnastics Australia National Risk Protection Program.

If you answered "NO" to the question on page 2, please complete the following information.

(a) All clubs that do not purchase insurance through the Program must supply evidence of pre-existing and current insurance as per the coverage requirements detailed below.

Failure to supply sufficient insurance documentation or evidence may cause delays with your affiliation.

(b) Please tick each box below and supply official documentation to verify that your Club's insurance policies comply with Gymnastics Australia's National Insurance Minimum Requirements.
GYMNASTICS AUSTRALIA'S NATIONAL INSURANCE MINIMUM REQUIREMENTS: *

I confirm that I have Public Liability Insurance for a minimum coverage of $20 Million in respect of any one occurrence (Gymnastics Australia's insurance product through Marsh provides coverage of $20 Million) I confirm that I have Property Insurance Coverage for a minimum of $500,000 for property in my care, custody and control (Gymnastics Australia's insurance product through Marsh provides coverage for $500,000) I confirm that I have Product Liability Insurance for a minimum coverage of $20 Million in respect of any one occurrence (Gymnastics Australia's insurance product through Marsh provides coverage of $20 Million) I confirm that I have Professional Indemnity Insurance for a minimum coverage of $10 Million (Gymnastics Australia's insurance product through Marsh provides coverage of $10 Million) I confirm that I have Extension Coverage for people participating in programs with my Club and Member to Member coverage for claims against another member (Gymnastics Australia's insurance product through Marsh includes this coverage) I confirm that both Gymnastics Victoria and Gymnastics Australia are listed as interested parties or insured. I confirm that if my insurance coverage ends before the 31st December 2019 that I will provide updated policy documentation upon renewal of my Club's insurance or contact Gymnastics Victoria if you would like to purchase liability insurance through the National Risk Protection Program.
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(c) In PDF format upload a copy of the Club’s Certificate of Insurance and additional insurance documentation. *
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(d) Club Declaration:

I, the undersigned, as authorised representative of the Club listed below and declare that the insurance policies held by the Club are current and meet ALL of the National Insurance Minimum Requirements as listed above at (b).

I have attached the Club's Certificate of Insurance and additional insurance documentation, where applicable, that demonstrates the insurance requirements have been met.

I understand that failure to supply the relevant insurance documentation may cause the Club's affiliation to be declined.
Club name: *
Authorised Club Representative *

First Name Last Name
Title of person making this declaration on behalf of the Club *
Date this Declaration is made *

Day Month Year Date Picker Icon
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2019 Club Change of Insurance Request

Insurance (cont'd)

The Gymnastics Australia Insurance program does not cover:

a) Workers compensation insurance / workcover

b) General building and/or other equipment insurance
Please confirm the Club has sufficient cover for:
a) Workers compensation insurance / Workcover *

Yes No Volunteer staff only
b) and in all States except NSW - General building and/or other equipment insurance *

Yes No
It should be noted that workers compensation insurance is a mandatory legal requirement for all employers (except exempt employers). Contact the WorkCover / WorkSafe authority in your state for further information.

For a quote on building and contents insurance go to: https://www.marshadvantage.com.au/business-products/businesspack.html.

2019 Club Change of Insurance Request

Club Change of Insurance - Declaration

I, the undersigned, declare I am a duly authorised representative of the Club listed below and all of the information supplied in this Form is correct at the time of application.
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Club name this declaration applies to: *
Name of Person *

First Name Last Name
Title of person making this declaration on behalf of the Club *
Date this declaration is made *

Day Month Year Date Picker Icon
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Name of Person Witnessing Declaration *

First Name Last Name
Date Witness observed Declaration *

Day Month Year Date Picker Icon
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Thankyou for your time! Please press Submit Form (then wait for up to 2 minutes while the form uploads). You will receive a confirmation email with the information submitted.
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Should be Empty:

(b) After due inquiry, are you aware of any claims, or incidents that may lead to a claim, relating to the following areas? Please tick each applicable box below.

(c) Club Declaration:

Insurance: Opt Out

(d) Club Declaration:

The Gymnastics Australia Insurance program does not cover: