Motorsport Affiliate Clubs Insurance

Please click the button below to view the Insurance Summary for the Affiliated Clubs Program

General Information
Name of Organisation affiliated with AASA*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is the organisation Incorporated?*
Are you a GST registered business?*
ABN Number*
If you claim less than 100% of the GST in your premium as an Input Tax Credit (ITC) please advise?*

eg, 90%
Contact Name*
Role / Position*
Mobile*
Email*
Website*
Period of Insurance required
From*
DD slash MM slash YYYY
To*
DD slash MM slash YYYY
Coverage Options
Public Liability
A$20,000,000 any one occurrence

Products Liability
A$20,000,000 any one occurrence and in the aggregate

Professional Liability (Errors and Omissions)
A$1,000,000

Management Liability
A$5,000,000 any one claim and in the aggregate

	NSW, QLD	ACT, VIC, WA	TAS
Base Premium	$700.00	$700.00	$700.00
GST	$70.00	$70.00	$70.00
Stamp Duty	$69.30	$77.00	$61.60
Horsell Duffy Langley Broker Fee Incl GST	$137.50	$137.50	$137.50
Insurer Fee Incl GST	$159.50	$159.50	$159.50
TOTAL PREMIUM PAYABLE	$1,136.30	$1,144.00	$1,128.60

Click here to view the HDL Financial Services Guide
Underwriting Information
Activities undertaken*
Organisation Numbers*
Membership Numbers Membership Sales Sponsorship Fees Event Fees Fundraising / Donations Employee Numbers
Please complete the table below with respect to club events and/or events promoted, managed and/or organises e.g. ride days, car shows, touring events, social events, children’s parties etc.:*
Event Type Event Description Estimated no. of events for the year Average no. of people attending event Maximum no. of people attending event
Are all participants required to sign a “disclaimer” to “release and indemnify” the organisation in regards to acknowledgment of risks, injury and obligations?*
Do you assume Liability under contract?*
If Yes, please supply details:*
Have you signed any contracts that waive your right for subrogation or recovery?*
If Yes, please supply details:*
Do you hold any property on behalf of a third party in your care, custody and/or control?*
If Yes, please supply details:*
Do you employ any persons?*
If Yes, please supply details:*
Does the organisation own a premises (excluding a track)?*
If Yes, please supply details:*
Does the organisation hire out the premises to others?*
If Yes, please supply details:*
Does the organisation require third parties hiring out the premises to have their own General Liability Insurance?*
If Yes, please supply details:*
Does the organisation own a track(s)?*
If Yes, please supply details:*
Does the organisation own any unregistered vehicles?*
If Yes, please supply details:*
Does the organisation operate a Licensed premise?*
If Yes, please supply details:*
Does the organisation host International Events*
If Yes, please supply details:*
Does the organisation perform any work overseas or generate any turnover from overseas activities?*
If Yes, please supply details:*
Does the organisation hold or cater for Children’s Parties*
If Yes, please supply details:*
Does the organisation hold a license to sell alcohol*
If Yes, please supply details:*
History and Claims
Has the Organisation or any Committee Members, Employees or Directors of the organisation: (please check all that apply)
- Had any insurance declined, or cancelled, proposal/application rejected, renewal refused, claim rejected, special conditions or excess imposed by an insurer?
- Has the Organisation or any employee ever been the subject of an investigation by a Regulatory body?
- Has the Organisation or any employee ever been subject to disciplinary action or be fined or penalised or?
- Has any employee of the Organisation ever been banned or prohibited from holding a position in any previous Organisation or as a Company Director?
- Are you aware, AFTER ENQUIRY, of any circumstances or incident which the Organisation or its employees, principals, directors or committee members has reason to suppose might afford grounds for any future claim such as would fall within the scope of the proposed insurance?
- Ever been declared bankrupt?
- Ever been involved in a company or business which became insolvent or was subject to any form of insolvency administration?
- Been convicted of any criminal offence (other than minor traffic offences) within the last 5 years?
If yes, please supply details:*
Have any claims for Liability or Indemnity been made by the organisation or anyone associated within the organisation in the last five years?*
If yes, please supply details:*
Have there been any incidents in the last five years that may result in claims against the applicants (whether the applicants were insured or not)?*
If yes, please supply details:*
Notation
Coverage Summary (Public and Products Liability)
The cover provided by Public and Products Liability Policy is for non-racing or race training activities. These activities are covered by AASA event sanction or other similar race sanctioning body.
Declaration
For and on behalf of the Organisation I represent that the above statements and facts are true and that no material facts have been suppressed or misstated. I understand that completion of this form does not bind coverage. The Organisation’s acceptance of the insurance quotation and the insurer’s acceptance of the Organisation’s proposal is required before cover may be bound and the policy issued.

I further declare that on behalf of the Organisation 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 Organisation 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 to the insurer making enquiries 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 the insurer 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.
Declaration agreement*
- I agree that I have read and agree to the above declaration
The completion of this proposal form does not automatically construe insurance coverage for the organisation. Confirmation of coverage will be confirmed once granted by the insurer. The insurer is Certain Underwriters at Lloyd’s of London. The insurance is brokered by Horsell Duffy Langley Pty Ltd trading as HDL Insurance Brokers, ABN 12 155 940 604, Financial Services Licence no. 422018.

Event Type	Event Description	Estimated no. of events for the year	Average no. of people attending event	Maximum no. of people attending event

Motorsport Affiliate Clubs Insurance

Please click the button below to view the Insurance Summary for the Affiliated Clubs Program

General Information

Coverage Options

Underwriting Information

History and Claims

Notation

Declaration

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