Renewal Declaration - Gym Insurance HQ

Insured Name:

Contact Name:

Contact Phone:

Contact Email:

Business Insurance Declaration

Your business insurance (stock, contents, fitout) would be:

Other Specify Below:

Had a claim or become aware of a possible claim?:
Yes No

If yes or Other to the above questions please provide complete details:

Liability Declaration

Estimated Turnover for next 12 months(eg: $10,000,000):

Do you anticipate any changes to the activities declared previously?
Yes No

Had a claim or become aware of a possible claim?
Yes No

If yes please provide complete details:

The following questions relate to any directors or partners.

Had a loss of licence, DUI or Drug offense in the last 5 years?
Yes No

Been declared bankrupt or put into receivership or liquidation?
Yes No

Been charged with or convicted of a criminal offence?
Yes No

Please provide additional information below:

Duty of Disclosure

Before you enter into a contract of general insurance with an insurer, You have a duty under the Insurance Contracts Act 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know that may be relevant to the decision of the insurer whether to accept the risk of the insurance and, if so, on what terms. The same duty arises at renewal, extension, variation or reinstatement of the policy.

Your duty, however, does not require disclosure of any matter:

That diminishes the risk insured under the policy;
That is of common knowledge;
That the insurer knows or, in the ordinary course of its business, ought to know; and
As to which compliance with your duty has been waived.

This duty continues until the time the policy is issued and applies to all persons to be covered under this policy.

If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the policy in respect of a claim or cancel a policy. If the non-disclosure is fraudulent, the may also have the option of avoiding the policy from its beginning.

By submitting this application form you hereby declare that:

You are the listed insured, or authorised by the listed insured to organise insurance on their behalf.
Yes No

If there is more than one insured, you are authorised to organise insurance on their behalf, and that if you disclosed personal information about any insured person or any other person, you have made them or will make them aware that you have provided their personal information to us and the types of third parties we may provide it to, the relevant purposes we and third parties will use it for, and how the insured person or other person can access it.
Yes No

The disclosed information is true and correct.
Yes No

You have not withheld or supressed any information concerning the details of this application.
Yes No

You have read the above duty of disclosure and are aware that should you not fully and truthfully disclose all relevant information, an insurer may decline a claim or void a policy
Yes No

You consent that any personal information you provide to Insurance HQ will be collected, stored, used and disclosed in accordance with our Privacy Policy/Financial Services Guide. We may provide your information to insurance companies and other intermediaries in order to provide insurance quotes and offer insurance terms to you or the companies that deal with your insurance claim (such as loss assessors and claims staff). We also may utilise the services Ins HQ (Asia) LLC Company Limited in processing and supporting our Australian staff.
Yes No

Would you like to speak to our staff in regards to any specific concerns?
Yes No

Would you like to speak to a specialist who can help with your life, trauma, total & permanent disablement, income protection and superannuation needs?
Yes No

Free Written