Trainer insurance for HPC members Name* First Last Trading Name*Are You a Resident of the Gold Coast*YesNoPostal Address*Suburb*State*Postcode*Email* Phone*Preferred Contact Method*EmailPhoneAre You*Self-EmployedEmployee / Contractor / Sub-ContractorIf you are self-employed, do you engage employees, voluntary workers, contractors or sub-contractors?*YesNoDo you buy / hire / sell equipment and/or machinery?*YesNoIf you have answered yes to the above question, please provide details of the equipment and/or machinery you buy/hire/sell.*Please tick and/or list all qualifications that you hold which are current:* Certificate III in Fitness Certificate IV in Fitness Current CPR Current First Aid Diploma of Fitness Other Provide details of Other QualificationsUpload a copy of your Certificate III (64Mb Limit)Upload a copy of your Certificate IV (64Mb Limit)Upload a copy of your Provide First Aid Certificate (64Mb Limit)Upload a copy of your CPR Certificate (64Mb Limit)Upload a copy of any other Certificates (64Mb Limit)Do you own, manage or operate a commercial fitness facility?YesNoDo you hire premises or studio space to conduct your coaching?*YesNoDo you provide an online training service to your members?*YesNoIf you have answered yes to the above question, this policy may not suit your needs. Please contact Arthur J. Gallagher on 07 3367 5146 for further questions Please choose an option below for the limit of cover you would like to be insured for: Certificate III & IV in Fitness Cert III & IV in Fitness - Option 1 Public & Products Liability: $10,000,000 Professional Indemnity: $5,000,000 Excess: $250 Cert III & IV in Fitness - Option 2 Public & Products Liability: $20,000,000 Professional Indemnity: $5,000,000 Excess: $250Option 1 - Premium $350.00 (Price Includes 1 Year Membership with HPC) Insurer: Lloyds Of London | PDS OMP v1.15 010814Option 2 - Premium $395.00 (Price Includes 1 Year Membership with HPC) Insurer: Lloyds Of London | PDS OMP v1.15 010814Claims ExperienceHave any claims for public liability and/or professional indemnity been made against you in the last five years?*YesNoIf Yes, please provide details belowDateDetails of incidentAmount PaidHave any incidents occurred in the last five years that might give rise to a claim for public liability and/or professional indemnity?*YesNoIf Yes, please provide details belowDateDetails of incidentAmount PaidPolicy ExclusionsPlease note that the Personal Trainers Insurance Policy does not provide cover for the following: - Activities for which you are not qualified - Activities which do not fall under the scope of your Certificate III & IV in Fitness qualification - Anyone working for you (Employees and Contractors/Sub-contractors) - Liability assumed under contract unless agreed in writing by us - Activities unrelated to your personal scope of practice - Owners/Operators of Commercial Fitness Facilities including home studios - Exercise Professionals who buy/sell/hire fitness equipment and/or machinery - Material Damage and Theft cover for your equipment Steroid and Illicit Drugs The above covers are available and should your business extend into areas outside of the scope of this policy. Please contact Arthur J. Gallagher for further information regarding insurance for these activities.Important NoticesPlease take note of the following statements pursuant to provisions of the Insurance Contracts Act 1984 UTMOST GOOD FAITH This insurance is a contract based on the utmost good faith requiring Underwriters and the Insured/Proposer to act towards each other with the utmost good faith in respect of any matter relating to this insurance. LIABILITY ASSUMED UNDER AGREEMENT Cover provided by this form of liability insurance does not cover liabilities which you have agreed to accept unless you would have been so liable in the absence of such agreement or unless agreed in writing by us. CLAIMS MADE The professional Indemnity Section is a claims made cover. This means that the policy covers you for claims first made against you during the period of insurance and notified to the insurer during such period of insurance. This extension does not provide cover in relation to: - Events which occured prior to the period of insurance or such earlier retroactive date as maybe stipulated in the policy schedule. - Claims made against you after the expiry of the period of insurance even though the event giving rise to the claim may have occured during the period of insurance. - Claims rising from or attributable to any facts, circumstances or occurences noted on the proposal for the current period of insurance or on any previous proposal or of which notice had been given under any previous policy. - Claims rising from or attributable to any facts, circumstances or occurences of which you were aware and knew (or ought reasonably to have realised) prior to the commencement of the period of insurance may give rise to a claim. - As explained above, the policy does not provide cover for claims made after the expiry of the period of insurance cover provided by the policy. AVERAGE PROVISION One of the issuing provisions of the Professional Indemnity Insurance policy provides that where the amount required to dispose of a claim exceeds the limit of Liability in the policy. Underwriters shall be liable only for a part of the total costs and expenses which shall be the same proportion of the total expenses as the Policy limit bears to the total amount required to dispose of the claim. YOUR DUTY OF DISCLOSURE Before you enter into a contract of general insurance with Underwriters, you have a duty, under the Insurance Act 1984, to disclose to Underwriters every matter that you know, or could reasonably be expected to know, is relevant to Underwriters' decision wether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to Underwriters before you renew, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of a matter: - That diminishes the risk to be undertaken by Underwriters: - That is common knowledge - That Underwriters know or in the ordinary course of their business, ought to know: - as to which compliance with your duty is waived by Underwriters. If you fail to comply with your duty of disclosure, Underwriters may be entitled to reduce their liability under the contract in respect of a claim or may cancel the contract. DECLARATION For and on behalf of the Applicant, I represent that the above statements and facts are true and that no material facts have been supressed or misstated. I understand that completion of this form does not bind coverage. The Applicant's acceptance of the company's quotation and company's acceptance of the applicant's proposal is required before cover may be bound and the policy issuedBy submitting your application, you agree to the above mentioned terms*Full NameUpon completion and acceptance of this form, Arthur J. Gallagher will contact you direct to arrange payment.