Insured Club Name*
Address*
Suburb*
State*
Postcode*
Contact First Name*
Contact Second Name*
Contact Phone No.*
Contact Email*
Year Established*
Number of Members*
Number of Employees*
Insurance Questions
Q1. Type of Organisation/Club*
Q2. Type of Activities*
Q3. When, Where and How are the Activities run?*
Q4. Do you hold events? Yes - Please answer Questions BelowNo - Go to Q5
Q4a. Dates & Locations of events being held
Q4b. Overview of what's happening at the event
Q4c. Expected Number of Attendees
Q4d. Will you be engaging contractors in connection with your event and will all contractors have their own insurance?
Q5. Will the Insured have any of the following?
Q5a. Rides/Amusements/inflatables? YesNo
Q5b. overnight camping or accommodation? YesNo
Q5c. fireworks or any other pyrotechnics? YesNo
Q5d. Any animals including but not limited to horse riding, petting zoos? YesNo
Q5e. The use of unregistered vehicles? YesNo
Q5f. The use of motorboats, aircraft? YesNo
Q5g. Trampolining? YesNo
Q6. Are you a Sporting Club or hold Sporting Events? Yes - Please answer Questions BelowNo - Go to Q7
Q6a. List of sports played
Q6b. Expected number of participants
Q6c. Is there First Aid officers onsite? N/AYesNo
Q6d. Do you have a working with children clearance? N/AYesNo
Q6e. Will all matches be overseen and controlled by qualified referees? N/AYesNo
Public Liability
Q7. Liability Limit $10,000,000$20,000,000
Q7a. What is your estimated total annual income from all sources (eg. grants, fees, donations, sales etc)?
Voluntary Workers
Q8. Do you require cover for Voluntary Workers? YesNo
Q8a. Number of Volunteers?
Management Liability
Q9. Do you require cover for Management Liability? Yes - Please answer Questions BelowNo - Go to Q10
Q9a. Have you formed a legal entity? N/AYesNo
Q9b. Has there been or is there now a pending claim against any person proposed for their insurance in their capacity of either Director or Officer of the Club/Association or any other Club/Association? N/AYesNo
Q9c. Has any person proposed for insurance ever been subject to disciplinary action, been fined or penalised or been subject to any inquiry in their capacity as Director/Officer? N/AYesNo
Q9d. Was the Club/Association trading profitably at the close of the last business month? N/AYesNo
Q9e. Has the Club/Association had a minimum of 2 years trading experience? N/AYesNo
Q9f. Has the Club/Association had 2 consecutive years of trading at a loss? N/AYesNo
Q9g. Do you have employees? N/AYes - Please answer Questions BelowNo - Go to Q9h
Do you have written employment contracts? N/AYesNo
Do you use outside employment counsel for employment advice? N/AYesNo
Do you have a policy that advice must be sought from the Human Resources Manager prior to terminating an employee? N/AYesNo
Do you conduct background checks on all employees prior to commencement of employment? N/AYesNo
Q9h. Do you require cover for Fidelity? N/AYes - Please answer Questions BelowNo - Go to Q10.
Do you have the following procedures in place when managing club money and assets?
Two signatures on all payments? N/AYesNo
Are dual authorities required for all fund transfers and refunds? N/AYesNo
Is a monthly reconciliation conducted of all bank accounts by someone who does not hand deposits, sign cheques, have access to electronic or mechanical signatures or conduct funds transfers? N/AYesNo
Is an external audit conducted on all accounts including payroll? N/AYesNo
Claims
Q10. Have any claims for Public Liability, Professional Indemnity or Property been made against the Applicant or anyone associated with the Applicant in the last five years? N/AYesNo
Q10a. Have there been any incidents in the last five (5) years that may result in claims against the Applicant, whether the Applicant was insured or not? N/AYesNo
Q10b. Has any Insurer ever declined, refused to renew or imposed special terms and conditions to any application, renewal or policy held by the Applicant? N/AYesNo
Q10c. Has the Applicant or anyone associated with the Applicant ever been declared bankrupt, convicted of a criminal offence, arson, fraud or dishonesty of any kind? N/AYesNo
Q10d. If you answered YES to any of the above please provide details:
Q11. Any other relevant information we may need to know?
