SportsPack Proposal Form

1. Full Name of Insured

2. Trading Name

3. Is the Club / Association Incorporated? Yes No

4. Contact Name

5. Phone (Pri) (Bus) (Fax)

6. Postal Address

State Postcode

7. Email

8. Website

9. Physical Address(es) of business:

(a)

State Postcode

(b)

State Postcode

(c)

State Postcode

10. List the Sporting Activities conducted

11. Period of Insurance from to

1. Does the centre / gymnasium have:

a) Swimming pool Yes No Length: m x m

b) Spa Yes No If yes, is it: Fixed Portable

c) Sauna Yes No

d) Tennis courts Yes No Number of courts

e) Squash / Racquet Ball courts Yes No Number of courts

f) Grandstand Yes No

g) Childminding facilities Yes No

h) Canteen / Cafeteria Yes No

i) Poker Machines Yes No If yes, number of machines:

Does the Club / Association:

j) Host International / National Events International National No

k) Own the Club premises? Yes No

If Yes, does the Club / Association have Building Liability Insurance? Yes No

l) Hire out those premises to others? Yes No

(Provide details of hiring)

If Yes, do you require third parties hiring out the premises to have their own Liability Insurance? Yes No

m) Own the equipment used? Yes No

(Please list equipment)

n) Hire out the equipment? Yes No

(List equipment and details of hiring)

o) Have a liquor licence? Yes No

(Provide Licence type)

p) Manufacture goods? Yes No

q) Sell goods to the public? Yes No

(List Goods manufactured / sold)

r) Has the Club / Association entered into any Contractual agreements? Yes No

If yes, please give details

2. Have you incurred any criminal convictions in the last five (5) years? Yes No

4. Have you ever been declared/adjudged bankrupt? Yes No

5. For each sport, give details of the following (please complete all questions)

a) Number of events / meetings / games / tournaments per year

b) Number of Spectators at each event / meeting / game / tournament (average)

c) Approximate duration of season

d) Number of the Committee members and Officials

e) Number of Registered players / members / teams

f) Number of Registered non playing members

g) The number of Clubs / Associations / Members to be covered

6. What was the centre / gymnasium’s turnover for the previous financial year? $

7. Is there a policy in place for members or workers with regard to:

a) Pregnancy? Yes No

b) Blood spillage? Yes No

c) Infectious diseases? Yes No

d) Discrimination? Yes No

If yes, please give details

8. a) Are all Coaches / Referees / Instructors to be covered qualified Yes No

If yes, please supply details including minimum qualification obtained

b) Number of Coaches / Referees / Instructors to be insured

Please attach a list (names and addresses) of all coaches / referees (note: cover not limited to those listed)

1. Have any claims for Public Liability and/or Professional Indemnity been made against the Proposer or anyone associated with the Proposer in the last five (5) years? Yes No

2. Have there been any incidents in the last five (5) years that may result in claims against the Proposer (whether or not the Proposer was insured)? Yes No

If you have answered yes to either of the above, please complete the following:

Year Number of Incidents Number of Claims made

Amount Settled: $ Amount Outstanding: $

Description of Incident/s

Name of previous insurer

3. Has any Insurer ever declined, refused to renew or imposed special terms and conditions to any application, renewal or policy held by the Proposer? Yes No

If yes, please give details

1. Public Liability (tick one)

$5,000,000 $10,000,000 $20,000,000

2. Professional Indemnity (tick one)

$2,000,000 $5,000,000

For any different amounts – please refer to office.

1. Approximate age of Premises Years

2. Construction: Walls Roof Floors Height

3. How long have you occupied? Years Months

4. Are you the only occupant Yes No

If no, please provide details

5. What is the neighbourhood (select applicable) Residential Commercial Industrial

6. Are the premises separated (by over 30 metres) from neighbouring buildings? Yes No

7. Sprinklers Yes No

If yes, serviced by whom?

8. Smoke Detectors Yes No

If yes, are they hot wired to an Alarm company or Fire Brigade? Yes No

Please provide details:

9. Hose reels / Extinguishers Yes No

Advise numbers:

10. Security

(a) Deadlocks on doors and windows Yes No

(b) Grills on windows Yes No

(c) Pad bolts on doors and windows Yes No

(d) Security tapes on windows Yes No

(e) Electronic security system / alarm Yes No

If Yes, provide details of type below:

(i) Name of Installer

(ii) Name of Service Company

(iii) Service frequency

(iv) Local Yes No

(v) Siren Yes No

(vi) Monitored Yes No If yes, by whom:

(vii) Alarm Type: Digital Dedicated Land Line/Securitel Wireless/Radio System

(viii) Does the Alarm cover all parts of the building? Yes No

(ix) Do you have Security Patrols? Yes No

If yes, by whom:

Patrol frequency:

(x) Do you have Security response to Alarm activation? Yes No

If yes, by whom:

1. Have any claims for Property been made in the last five (5) years? Yes No

2. If uninsured in the last five (5) years have there been any incidents in that time that may have resulted in a claim? Yes No

If you have answered yes to either of the above, please complete the following:

Year Number of Incidents Number of Claims made

Amount Settled: $ Amount Outstanding: $

Description of Incident/s

Name of previous insurer

3. Has any Insurer ever declined, refused to renew or imposed special terms and conditions to any application, renewal or policy held by the Proposer? Yes No

If yes, please give details

1. Replacement Yes No

2. Indemnity Yes No

3. Sum Insured

Building(s) $

Plant/Machinery & all contents (Ex Stock) $

Stock $

Removal of debris $

Other (please specify) $

TOTAL $

1. Income / Revenue $

2. Claims Preparation Costs $

3. Additional Increase in Cost of Working $

4. Payroll - Do you require Payroll to be insured separately Yes No

(a) Percentage of Annual Payroll required (tick) 10% 25% 50% 75% $

(b) Book Debts $

(c) Gross Rentals $

Total $

5. Indemnity Period Months

6. Additional Uninsured Working Expenses

7. Are books of accounts / records kept in fire resistant safes when not in use? Yes No

8. Are duplicate records kept off site? Yes No

1. Do you require Theft Insurance Yes No

2. Stock in trade including clothing (excludes alcohol & tobacco products) $

3. Alcohol / Tobacco $

4. Contents including sporting equipment $

5. Other (please specify) $

6. Damage to premises by burglars $

TOTAL Sum Insured $

7. Drugs and other substances

(a) Describe the type / nature?

(b) Specify security arrangements:

1. Money in Transit $

2. Money on business Premises (working hours) $

3. Money on business Premises (outside working hours) $

4. Money in Safe or Strongroom $

5. Money in Personal Custody $

6. Additional damage to safes & strongrooms (above basic $1,000 policy cover) $

7. Other (please specify) $

Note: Money on Premises is limited to $1,000 outside business hours unless contained in a securely locked TDR (torch and drill resistant) safe or strong room

1. External Glass Yes No Replacement Value: $

2. External Signs Yes No Replacement Value: $

3. Internal Glass Yes No Replacement Value: $

4. Extensions (included)

(a) Temporary Shuttering $ 1000

(b) Damage to Frames $ 1000

(c) Signwriting $ 1000

For and on behalf of the Applicant I represent that the above statements and facts are true and that no material facts have been suppressed or mis-stated. I understand that completion of this form does not bind coverage. The Applicant’s acceptance of the company’s quotation and the company’s acceptance of the Applicant’s proposal is required before cover may be bound and the policy issued.

I further declare that on behalf of the Club / Association I:

• have either completed all the questions on this form personally or they have been completed by somebody else on my behalf and the answers have been checked for fullness and accuracy by me.

• am a duly authorised officer of the Club / Association applying for insurance for the purpose of completing this application.

• have read and understood the information concerning the duty of disclosure, average provisions, utmost good faith and all other important notices.

• agree on behalf of the applicant to Sportscover obtaining from the applicant’s previous insurer(s) any information it may need about prior claims or insurance history.

• agree to Sportscover making enquires from any third party to verify claims history and other information disclosed herein or statements made by the applicant or its representatives in making this application.

• agree to Sportscover disclosing to any insurance intermediary appointed by the applicant or to any former or future insurer of the applicants the claims history or any other information as may be determined.