Renewal Declaration - Gym Insurance

Insured Name:

Contact Name:

Contact Phone:

Contact Email:

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:

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:

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:

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

Business Insurance Declaration

Liability Declaration

The following questions relate to any directors or partners.

Duty of Disclosure