MAIA Insurance Application

Is your MAIA insurance current?(*)
Is your MAIA insurance current?
Please specify your position in the company
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Are you a current MAIA member?(*)
Are you a current MAIA member?
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School Details

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Do you have an ABN?(*)
Do you have an ABN?
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How long have you been in business?(*)
How long have you been in business?
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Business Principal

The owner / main contact of your school / business

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Contact / Admin Officer

The person who should receive all membership / insurance notifications from MAIA

Our contact / admin officer is the same as above(*)
Our contact / admin officer is the same as above
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Invalid email address.
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School/Training Location*

If more than one location, only add main school's address.
It's Australia wide cover so you don't have to list all locations.

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Past Claim Information of the Trading Entity*

Are you aware of any insurance being declined or cancelled, application/proposal rejected, renewal refused, claim rejected, or special conditions or excess imposed by any insurer?(*)
Are you aware of any insurance being declined or cancelled, application/proposal rejected, renewal refused, claim rejected, or special conditions or excess imposed by any insurer?
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Are you aware of any claims made against you in the past 5 years?(*)
Are you aware of any claims made against you in the past 5 years?
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Have you ever, either alone or jointly with others, been declared bankrupt or subject to any form of insolvency administration (e.g. liquidation or receivership)?(*)
Have you ever, either alone or jointly with others, been declared bankrupt or subject to any form of insolvency administration (e.g. liquidation or receivership)?
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Training / Coaching Experience of Business’s Principal*

How many years have you been teaching?(*)
How many years have you been teaching?
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Operation Details*

Is the Insured's facility ever unsupervised by staff when open for use?(*)
Is the Insured's facility ever unsupervised by staff when open for use?
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Are all instructors accredited?(*)
Are all instructors accredited?
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DECLARATION*

I/We the undersigned duly authorised person(s) declare that:

  1. I am/we are authorised by the Proposer/s to sign this Proposal Form; and
  2. the above statements are correct, true and complete; and
  3. no information material to this Proposal Form has been withheld; and
  4. I/we have read the important facts which you have put before me/us and I/we understand the advice given in relation to the duty of disclosure; and
  5. I/we have diligently made all necessary and detailed enquiries in order to comply with the duty of disclosure; and
  6. I/we understand that no insurance is in force until such time as the insurer has confirmed acceptance of the proposed insurance; and
  7.  I/we undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance; and
  8. I/we acknowledge that the Insurer relies on the information and representations in this Proposal Form and otherwise made by me/us in relation to this insurance.
Sign Above
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Please type your full name.
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Contact Details

All Insurance communication in respect to invoicing, issuing certificates of currency, updating details, payments and claims will be managed through MAIA Office.

Martial Arts Industry Association 
Email: info@maia.com.au