Insurance Declaration Insurance Declaration Complete this form is you already have a Pilates Aotearoa membership, and are adding insurance. Step 1 of 2 50% Insurance Membership with Pilates Aotearoa requires you have appropriate insurance. With your Pilates Membership you can purchase discounted insurance we offer, or you can arrange this privately. The Insurance Covers: -Professional Indemnity -Public Liability -Statutory Liability Please see Pilates Aotearoa's Insurance Information for more details: Pilates Aotearoa Insurance informationName First Last Email Would you like to purchase insurance with your Pilates Aotearoa Membership?(Required) No - I have my own insurance or am covered by my employer Yes - I would like to purchase insurance Please complete the Insurance Declaration below. A. List activities you undertake:(Required)(e.g Pilates Teaching/group instruction, one on one sessions). These activities must be within your role as an exercise professional, and within the scope of your knowledge, competency and skill.B. Have you had any previous claims in respect to the insurance being applied for?(Required)C. What was your total income in the last completed financial year?(Required) Under $50,000 Over $50,000 Just started (excl GST) If you have just started business please tick “just started”Please write amountE. Have you ever been subject to disciplinary proceedings for professional misconduct?(Required) Yes No Please provide more detailsF. Are you aware of any claims, or circumstances which may result in claims against you?(Required) Yes No Please provide more details(Required)Lumley Insurance Agreement(Required) On behalf of all proposed Insureds I declare and agree that: a) All information provided, in this proposal or attachments, is true and complete in every respect and that no Material Facts remain undisclosed; b) If this risk is accepted, such information will be incorporated into and form the basis of the contract of insurance; c) I/We understand that Lumley requires this information in order to evaluate this proposal and that the Privacy Act 1993 entitles me/us to have access to, and request the correction of, any information retained; d) Lumley is authorised to disclose information to its advisers, reinsurers, other insurers and parties with a financial interest in the subject matter of this proposal; e) Lumley is authorised to check details against the Insurance Claims Register and to place information on the Insurance Claims Register which other insurers can access; f) Lumley is authorised to obtain from other parties any information which may be relevant to the acceptance of this risk; g) The signing of this proposal does not bind either party to complete the contract and that no cover will be in force until confirmed by Lumley. I/We agree to accept the terms, exceptions and conditions contained in the Professional Indemnity Insurance policy as modified or extended by any endorsements thereon or the policy schedule or on any certificate of insurance issued to me/us by Lumley in lieu of a policy. I/We agree that REPs reserves the right to change insurer at any time. This may result in changes to the terms and conditions of the cover, but REPs will ensure the level of cover is comparable. Lumley, a business division of IAG New Zealand LimitedTotal Total Terms and Payment Consent(Required) I confirm I have read and agree to the terms and conditionsCAPTCHA EMAIL info@pilatesaotearoa.org.nz PHONE 0800 11 51 63 MAILING ADDRESS P O Box 22114 Christchurch, 8140 LOCATION Unit 8/14 Broad Street Woolston Christchurch, 8023
