Details of Party to be Insured

Note: If you would like a quote for multiple fitness centre locations, please complete a new quote request for each location.

Entity Name *Company Name eg. Sampletown Fitness Pty Ltd

Business Name *Trading Name - eg. Anytime Sampletown

Contact Email *

Business Phone Number *

Address of Club to be Insured *

Postal Address *

Number of Staff *

Annual Gross Revenue *

Preferred Policy Inception Date (when would you like your policy/policies to start?) *

Business Package Insurance

Property Details

Landlords entity name detailed within lease to be listed as an interested party (if applicable) *

Have you made any property claims in the last 3 years? *

Yes (can be multiple)No

What occurred?

Date of Incident

Amount paid by insurer

Approx. Year Built *

Are the walls insulated with expanded polystyrene (foam type material) to your knowledge? *

NoYes

Flooring *

Concrete SlabBricksWooden Floor Foundation

Location *

Street facingWithin a shopping centreWithin an industrial complex

Fire & Perils

Replacement value of contents / stock *Definition of Contents: Fit-out, ancillary equipment, gym equipment and any other items which are not fixed to the premises

Building replacement value * If applicable - property owner only

Excess *

$500$1,000

Select your preferred excess level

Business Interruption

Indemnity Period for Business Interruption *

12 Months24 Months

Burglary / Theft

Theft Sum Insured *

Money

Money Sum Insured

$3,000$5,000$10,000

Glass

Internal & External Glass has been selected for this policy.

Machinery Breakdown

Machinery Breakdown - Total Number of units/machinery to be covered *

Machinery Breakdown Limit Per Unit *

$5K$10KNot required

Do you undertake annual preventative maintenance for all the machinery? *

YesNo

Electronic Equipment

Laptops *

Office computers / equipment (excluding laptops) *

Do you have any other electronic equipment to be insured under this policy? *

YesNo

Other Item - Description

Sum Insured

Optional Extension - Cost of restoring data Sum Insured

Combined General Liability, Professional Indemnity & Management Liability

Would you like to receive a quote for cover under the Combined General Liability, Professional Indemnity & Management Liability Policy? *

YesNo

Professional Indemnity

Have any Claims been made against the Proposed Insured for professional negligence, error or omission in the last 5 years? *

YesNo

Please provide the following for each claim in this period; details of claim, total amount claimed and any insurer payments made. *

Is the Proposed Insured aware, after enquiry of any circumstances or incident, which may give rise to a Claim? *

NoYes

Please provide further details

Management Liability

1. After enquiry, is the Proposed Insured aware of any facts or circumstances which might afford valid grounds for any future claim(s) or which would indicate the probability of any such claim(s) under any section of the cover for which it has applied? *

YesNo

Please provide details

2. Within the last three (3) years, has the Proposed Insured been the subject of any complaint, suit, inquiry or notice of a hearing from any State, Territory or Federal regulatory body, or any other party? *

YesNo

Please provide details

3. Within the last three (3) years, has the Proposed Insured discovered any losses from employee dishonesty, burglary, robbery, disappearances, destruction or forgery? *

YesNo

Please provide details

4. Has the Proposed Insured been declined, had cancelled or non-renewed any insurance policies for any of the coverages for which it has applied? *

YesNo

Please provide details

5. Have any claims ever been made against the Proposed Insured or any of its Directors, Officers or employees for wrongful termination, discrimination intimidation or sexual harassment? *

YesNo

Please provide details

6. In the past five (5) years, has the Proposed Insured has a Workplace or Environmental incident (including a workplace facility, serious injury or dangerous incident) that either required notification to, or warranted investigation by, a Regulatory Authority or a compulsory requirement to attend any hearing, inquiry, prosecution or other commission? *

YesNo

Please provide details

7. Has the Proposed Insured ever had any Insurer decline a proposal or cancel or refuse Management Liability Insurance? *

YesNo

Please provide details

General Questions

Sustained more than 3 losses or had losses totalling in all more than $5,000 in the last 3 years for those sections to be insured by this contract (excluding motor vehicles and management liability)? *

YesNo

Please provide further information

Year *

Description *

Amount *

Ever had an insurance policy cancelled, declined or terms imposed? *

YesNo

Please provide details *

During the past five years been declared bankrupt or insolvent? *

YesNo

Please provide details *

During the past five years been convicted of a criminal offence? *

YesNo

Please provide details *

Other Cover

Are you interested in receiving quotations for any additional covers? *

Yes, Cyber Insurance (NEW exclusive rates for Anytime Franchise Owners)Yes, Motor Vehicle InsuranceYes, Workers Compensation (WA, NT & TAS Franchisees Only)Yes, OtherNo thank you, we are not interested in receiving quotes for any additional covers.

Additional Comments

Completed by (First Name) *

Completed By (Last Name) *

Position (Job Title) *

By submitting this form you agree you are authorised to complete this information of behalf of the insured and that all information provided is accurate as at the submission date.

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