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LICENCES
ANNUAL LICENCES
DAY / EVENT LICENCES
OFF ROAD LICENCES
FAQs
OFFICIALS
MEDIA
PERMITS
Event Info
INSURANCE
VEHICLE PASSPORTS
CONTACT US
ABOUT
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FAQs
CAREERS
Motorsport Affiliate Clubs Insurance
Please click the button below to view the Insurance Summary for the Affiliated Clubs Program 2019-2020
AFFILIATED CLUBS INSURANCE SUMMARY
General Information
Name of Organisation affiliated with AASA
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Is the organisation Incorporated?
*
Please select
Yes
No
Are you a GST registered business?
*
Please select
Yes
No
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
*
Date Format: DD slash MM slash YYYY
To
*
Date Format: 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?
*
Please select
Yes
No
Do you assume Liability under contract?
*
Please select
Yes
No
If Yes, please supply details:
*
Have you signed any contracts that waive your right for subrogation or recovery?
*
Please select
Yes
No
If Yes, please supply details:
*
Do you hold any property on behalf of a third party in your care, custody and/or control?
*
Please select
Yes
No
If Yes, please supply details:
*
Do you employ any persons?
*
Please select
Yes
No
If Yes, please supply details:
*
Does the organisation own a premises (excluding a track)?
*
Please select
Yes
No
If Yes, please supply details:
*
Does the organisation hire out the premises to others?
*
Please select
Yes
No
If Yes, please supply details:
*
Does the organisation require third parties hiring out the premises to have their own General Liability Insurance?
*
Please select
Yes
No
If Yes, please supply details:
*
Does the organisation own a track(s)?
*
Please select
Yes
No
If Yes, please supply details:
*
Does the organisation own any unregistered vehicles?
*
Please select
Yes
No
If Yes, please supply details:
*
Does the organisation operate a Licensed premise?
*
Please select
Yes
No
If Yes, please supply details:
*
Does the organisation host International Events
*
Please select
Yes
No
If Yes, please supply details:
*
Does the organisation perform any work overseas or generate any turnover from overseas activities?
*
Please select
Yes
No
If Yes, please supply details:
*
Does the organisation hold or cater for Children’s Parties
*
Please select
Yes
No
If Yes, please supply details:
*
Does the organisation hold a license to sell alcohol
*
Please select
Yes
No
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?
*
Please select
Yes
No
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)?
*
Please select
Yes
No
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.