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NATIONAL RUGBY LEAGUE | WHOLE OF GAME PROGRAM
QUEENSLAND RUGBY LEAGUE 2017 INSURANCE DECLARATION Name of club: To be completed and returned directly to Arthur J. Gallagher, by no later than 28 February 2017.
Queensland Rugby League 2017 Insurance Declaration
Arthur J. Gallagher Co (Aus) Limited 34 005 543 920 Level 2, 601 Coronation Drive Toowong QLD 4066 GPO Box 1113 Brisbane QLD 4001 T: 1800 SPORT 0 (1800 776 780) F: (07) 3367 5100 www.ajg.com.au Attention: Committee Members QRL Affiliated Clubs and Local Leagues
Dear Committee Members, Re: 2017 Whole of Game Insurance Program It is compulsory that each Affiliated Club and Local League (where applicable) effects for its Teams, the minimum level of Insurance cover by 28 February 2017. Please note Club Management Liability (Part B. page 6) is now compulsory and must be selected. The level of benefits provided by the Program are not “comprehensive” and as such the QRL and Arthur J. Gallagher encourage all participants to take out Private Health, Life and Income Protection Insurance according to their own individual circumstances. It must be clearly understood that after being informed of the level of cover taken out by a Club or Local League, it is an Individual’s responsibility to ensure that he / she has adequate Insurance cover for his / her needs. It is essential that each Club and Local League Executive advise all Players, Officials and Volunteers associated with its Teams of this level of Insurance cover and any additional cover it has taken out. To assist in advising all participants of their minimum insurance cover we have produced a “Quick Guide to the 2017 NRL Community Insurance Program” that must be distributed to all participants by Clubs and Local Leagues (where applicable). Your 2016 cover will expire at 4pm on 31 December 2016. Arthur J. Gallagher will arrange for the minimum 2017 cover to take effect from 4pm 31 December 2016 for all Affiliated QRL Clubs and Local Leagues. You must complete this “Insurance Program Declaration” and return directly to Arthur J. Gallagher, by 28 February 2017 together with your premium payment / loan agreement and a copy of any contractual agreements entered into by the organisation.
Yours sincerely
Endorsed by
Terry Berryman
Rob Moore
Sports Team Leader Arthur J. Gallagher
Managing Director QLD Rugby League
Arthur J. Gallagher. NRL Whole of Game Program
Important Dates and Information 4pm 31 December 2016 to 4pm 28 February 2017 Training and participating in trial / non fixture games sanctioned by QRL: Cover provided to those Players / Coaches who: • Were registered with a QRL Affiliated Club / Local League for the 2016 season; or • Are registered with a QRL Affiliated Club / Local League for the 2017 season; or • Have listed on a trial and train register with a QRL Affiliated Club / Local League for the 2017 season.
4pm 28 February 2017 to 4pm 1 October 2017 No cover whatsoever unless Players / Coaches: • Are registered with a QRL Affiliated Club / Local League for the 2017 season; and • The Club / Local League has submitted its completed “Insurance Program Declaration” together with its payment / loan agreement to Arthur J. Gallagher.
4pm 1 October 2017 to 4pm 31 December 2017 Participating in fixture games sanctioned by QRL: Cover provided to those Players / Coaches who: • Were registered with a QRL Affiliated Club / Local League for the 2017 season. Training and participating in trial / non fixture games sanctioned by QRL: Cover provided to those Players / Coaches who: • Were registered with a QRL Affiliated Club / Local League for the 2017 season; or • Are registered with a QRL Affiliated Club / Local League for the 2018 season; or • Have been listed on a trial and train register with a QRL Affiliated Club / Local League for the 2018 season.
Important Information Please Note: A person who has reached the age of forty (40) years or is reaching that age during a football season, and desires to participate in a game of rugby league under these Rules, must lodge with his Player’s Agreement each year a Certificate or Report issued by a Registered Sports Physician or Medical Specialist in Queensland stating that the person does not have any apparent impediment, declared or otherwise, that would preclude his participation in a body contact sport. Please also note that the Public Liability and Player Accident insurance covers under the NRL Community Insurance Program which covers your club for all Rugby League activities does not extend to include non sanctioned Rugby League Carnivals or other ancillary sports such as Touch Football competitions. Arthur J. Gallagher has developed a policy specifically for One Off Rugby League Carnivals and other ancillary sports such as Touch Football competitions, which will protect your club for any incidents relating to these activities. Please note major Policy Exclusions of the Insurance Handbook.
QRL 2017 Insurance Declaration | Page 3
Queensland Rugby League 2017 Insurance Declaration Club Details General Details Full name of the Club (as per Incorporation Certificate) Are you registered for GST purposes?
Yes
No
What is your ABN? Postal Address of Club Postcode Club Grounds Address Postcode Club
President
Treasurer
Secretary
Name Email
Telephone (B/Hrs) Fax Mobile Has your Club applied for affiliation for the 2017 season and been accepted by the relevant Division? Yes
No
Division (Please circle)
South East
Central
Northern
What League does your club play in Club Activities Does your Club hold a liquor license, outside ‘QRL game day’?
Yes
No
If Yes, what are your trading hours?
Does your Club have poker machines?
Yes
No
If Yes, how many?
What is your Club’s annual turnover?
$
Does your Club operate another sport
Yes
No
If Yes, what type
Previous Public Liability Claims
Yes
No
If Yes, please attach details
Childminding / Playground
Yes
No
Public Gymnasium
Yes
No
Live Entertainment (Bands etc)
Yes
No
Dance Floor
Yes
No
After 1.00am Trading
Yes
No
Provide Outside Catering
Yes
No
Closed Circuit TV Monitoring installed
Yes
No
Do you hire out your club to third parties
Yes
No
Arthur J. Gallagher. NRL Whole of Game Program
(I.e. revenue prior to expenses)
If Yes, estimated income $
Property Insurance Renewal/Quote Request Declaration Property Sums Insured Material Damage Buildings
$
Contents
$
Stock
$
Lighting & Towers
$
Other
$
Description
Other
$
Description
Mobile Machinery (Tractors / Ride on Mowers etc) $
Description
Registered
Mobile Machinery
$
Yes
No
Mobile Machinery
$
Yes
No
Machinery Breakdown (Pumps, Motors & Compressors) Description Required $
Description
Required
Limit any one loss
$25,000
Yes
No
Deterioration of stock
$2,500
Yes
No
Electronic Equipment & Breakdown (Computers, Hardware & Software) $
Description
Required
Limit any one loss
$5,000
(Scoreboard limited to $10,000)
Yes
No
Data Restoration
$2,500
Yes
No
Increased cost of working
$2,500
Yes
No
Business Interruption Gross Profit
$
Payroll (if insured separately)
$
Other Insurances Does your Club take out any additional insurance cover than that provided via QRL / Arthur J. Gallagher? Yes
No
Type of Policy
If yes, please provide details below Due Date
Insurer
Broker
PLEASE NOTE: Completion of this section does not automatically effect insurance. If your changes are urgent, please contact us on 1800 SPORT 0 QRL 2017 Insurance Declaration | Page 5
Queensland Rugby League 2017 Insurance Declaration Cost per Team – PART A (Compulsory - if applicable) Stamp Duty Exempt (**Exemption Required)
Not Stamp Duty Exempt
Under 6
@ $ 62
or $ 65
=$
Under 7
@ $100
or $105
=$
Under 8
@ $100
or $105
=$
Under 9
@ $178
or $185
=$
Under 10
@ $178
or $185
=$
Under 11
@ $254
or $265
=$
Under 12
@ $254
or $265
=$
Under 13
@ $437
or $450
=$
Under 14
@ $437
or $450
=$
Under 15
@ $635
or $650
=$
Under 16
@ $736
or $755
=$
Under 17
@ $824
or $845
=$
Under 18
@ $908
or $930
=$
Grade
Number of Teams
Total Part A
Premium
$
Cost per Club Entity – PART B (Compulsory) Category Club Management Liability
Stamp Duty Exempt (**Exemption Required)
Not Stamp Duty Exempt
Total Part B
$315
$330
$315 or $330 (please circle)
** To qualify for the Stamp Duty Exempt Premium, you must provide a copy of your Stamp Duty Exemption Certificate each year. If you do not provide this certificate, the Stamp Duty Exempt premium, will not be accepted. To obtain certificate you must contact the Office of State Revenue. Details can be found at: https://www.business.qld.gov.au/industry/professional-financial/insurance-duty/calculating/exemptions
Arthur J. Gallagher. NRL Whole of Game Program
Cost per Team – PART C (Compulsory - if applicable) Stamp Duty Exempt (**Exemption Required)
Not Stamp Duty Exempt
Under 19
@ $1,920
or $1,950
=$
Under 20
@ $2,890
or $2,930
=$
Under 22
@ $2,890
or $2,930
=$
A Grade
@ $2,890
or $2,930
=$
B Grade
@ $2,890
or $2,930
=$
C Grade
@ $2,890
or $2,930
=$
Opens
@ $2,890
or $2,930
=$
Masters
@ $2,890
or $2,930
=$
Womens
@ $2,890
or $2,930
=$
Intrust Super Cup
@ $2,890
or $2,930
=$
FOGS Colts
@ $2,890
or $2,930
=$
Grade
Number of Teams
Total Part C
Premium
$
Loss of Income option – PART D PLEASE NOTE: Loss of income is not automatically included for senior teams / players. You can either take out these options by entering into the below table, or direct your teams / players to Arthur J Gallagher on 1800 SPORT 0 (1800 776 780), for an individual quote should your club elect not to take up this benefit on their behalf. Senior teams or Individual Player Loss of Income (Refer page 5-6 of the handbook)
Weekly Benefit
Premium
Team grade / Player Name:
$
Team grade / Player Name:
$
Team grade / Player Name:
$ Total Part D
$
Total cost of insurance Total Premium Payable (Part A, B, C, D):
$
QRL 2017 Insurance Declaration | Page 7
Queensland Rugby League 2017 Insurance Declaration Duty of Disclosure Before you enter into a contract of general insurance with an Insurer, you have a duty at law to disclose to the Insurer anything that you could be reasonably expected to know is relevant to the Insurer’s decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to the Insurer before you renew, extend, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of matter: • • • •
that diminishes the risk to be undertaken by the insurer; that is of common knowledge; that your insurer knows or, in the ordinary course of business ought to know; as to which compliance with your duty is waived by the insurer.
If you fail to comply with your duty of disclosure, the Insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the Insurer may also have the option of avoiding the contract from its beginning.
Declaration & Acknowledgments I/We declare and acknowledge that I/We: • have not suppressed, misrepresented or misstated any material information within my knowledge likely to affect the Insurers decision as to my eligibility for insurance and the answers given in the Proposal and the completed quote questionnaire are in every respect true and correct. • have received, read and fully understand the details contained in the 2017 NRL Community Insurance Program Handbook. Furthermore, I acknowledge the property insurance program is an optional policy and that cover will only commence upon written acceptance of a formal quotation provided by Arthur J. Gallagher. • acknowledge that the public liability insurance component of the insurance program is intended to provide cover for “normal” activities of Rugby League. Activities outside of Rugby League including but not limited to fundraising and social activities may not be covered under this policy and should be referred to Arthur J. Gallagher for clarification. • subject to the Insurance (Agents and Brokers) Act, if this Proposal is accepted by the Insurer, the Proposal, the Policy and Schedule issued shall constitute the entire agreement between you and us, and shall supersede any prior representations or warranties.
Signature of President, Treasurer or Secretary Name of President, Treasurer or Secretary
Date
/
/
Arthur J. Gallagher. NRL Whole of Game Program
Important Checklist General Has the Duty of Disclosure been signed and dated? Have you attached copies of any contractual Agreements signed by the Club / Local League? If you are claiming Stamp Duty Exempt status have you attached a copy of your certificate from the Office of State Revenue?
Yes
No
Yes
No
Yes
No
Payment Options (tick) 1.
Cheque for $
made payable to “Arthur J. Gallagher” is attached
2. Direct Debit Option – if you wish to pay by an on-line direct debit transfer, please forward your completed declaration. On receipt we will email your invoice back to you, with your own clubs dedicated Direct Debit details for easy transfer 3. Premium Funding – if you wish to Fund please contact Arthur J. Gallagher on 1800 SPORT 0 to obtain a Funding quote, as per below process.
NOTE: If you would like a funding quotation for monthly instalments please follow these steps: 1. Phone 1800 SPORT 0 (1800 776 780) and advise that you are a “QRL Club requesting a Premium Funding Quotation”. 2. Have your total team numbers ready. 3. A quote & contract will then be emailed to you 4. If you accept the funding contract, simply complete, sign and return directly to Arthur J. Gallagher, together with your completed 2017 QRL Insurance Program Declaration.
REMINDER: Completed documents must be forwarded directly to Arthur J. Gallagher, by no later than the 28 February 2017.
Please return the completed Declaration together with your Payment / Loan Agreement directly to AJG Sport, GPO Box 1113, BRISBANE QLD 4001 QRL 2017 Insurance Declaration | Page 9
Queensland Rugby League 2017 Insurance Declaration Contacts – Arthur J. Gallagher Branch
Sport, Leisure and Recreation team Level 2, 601 Coronation Drive, TOOWONG QLD 4066 Postal Address:
GPO Box 1113 BRISBANE QLD 4001
Team Leader
Assistant Account Executive
Assistant Account Executive
Arthur J. Gallagher. NRL Whole of Game Program
Phone:
1800 SPORT 0 (1800 776 780)
Fax:
07 3367 5100
Terry Berryman Phone:
(07) 3367 5010
Mobile:
0438 596 939
E-mail:
[email protected]
Julian Jemmott Phone:
(07) 3367 5146
E-mail:
[email protected]
Bryce Stevens Phone:
(07) 3367 5072
E-mail:
[email protected]
QRL 2017 Insurance Declaration | Page 11
Arthur J. Gallagher Insurance Brokers. AFSL 238312. To the extent that any material in this brochure may be considered advice, it may only be considered general advice as it does not take into account your personal objectives, needs or financial situation. Arthur J. Gallagher urges you to read the relevant policy wording and consider whether any products are appropriate for your situation before making a decision to acquire insurance. Ref 1342-Dec16
1800 SPORT 0 (1800 776 780)
NATIONAL RUGBY LEAGUE | WHOLE OF GAME PROGRAM
QUEENSLAND RUGBY LEAGUE 2017 INSURANCE DECLARATION Name of club: To be completed and returned directly to Arthur J. Gallagher, by no later than 28 February 2017.
Queensland Rugby League 2017 Insurance Declaration
Arthur J. Gallagher Co (Aus) Limited 34 005 543 920 Level 2, 601 Coronation Drive Toowong QLD 4066 GPO Box 1113 Brisbane QLD 4001 T: 1800 SPORT 0 (1800 776 780) F: (07) 3367 5100 www.ajg.com.au Attention: Committee Members QRL Affiliated Clubs and Local Leagues
Dear Committee Members, Re: 2017 Whole of Game Insurance Program It is compulsory that each Affiliated Club and Local League (where applicable) effects for its Teams, the minimum level of Insurance cover by 28 February 2017. Please note Club Management Liability (Part B. page 6) is now compulsory and must be selected. The level of benefits provided by the Program are not “comprehensive” and as such the QRL and Arthur J. Gallagher encourage all participants to take out Private Health, Life and Income Protection Insurance according to their own individual circumstances. It must be clearly understood that after being informed of the level of cover taken out by a Club or Local League, it is an Individual’s responsibility to ensure that he / she has adequate Insurance cover for his / her needs. It is essential that each Club and Local League Executive advise all Players, Officials and Volunteers associated with its Teams of this level of Insurance cover and any additional cover it has taken out. To assist in advising all participants of their minimum insurance cover we have produced a “Quick Guide to the 2017 NRL Community Insurance Program” that must be distributed to all participants by Clubs and Local Leagues (where applicable). Your 2016 cover will expire at 4pm on 31 December 2016. Arthur J. Gallagher will arrange for the minimum 2017 cover to take effect from 4pm 31 December 2016 for all Affiliated QRL Clubs and Local Leagues. You must complete this “Insurance Program Declaration” and return directly to Arthur J. Gallagher, by 28 February 2017 together with your premium payment / loan agreement and a copy of any contractual agreements entered into by the organisation.
Yours sincerely
Endorsed by
Terry Berryman
Rob Moore
Sports Team Leader Arthur J. Gallagher
Managing Director QLD Rugby League
Arthur J. Gallagher. NRL Whole of Game Program
Important Dates and Information 4pm 31 December 2016 to 4pm 28 February 2017 Training and participating in trial / non fixture games sanctioned by QRL: Cover provided to those Players / Coaches who: • Were registered with a QRL Affiliated Club / Local League for the 2016 season; or • Are registered with a QRL Affiliated Club / Local League for the 2017 season; or • Have listed on a trial and train register with a QRL Affiliated Club / Local League for the 2017 season.
4pm 28 February 2017 to 4pm 1 October 2017 No cover whatsoever unless Players / Coaches: • Are registered with a QRL Affiliated Club / Local League for the 2017 season; and • The Club / Local League has submitted its completed “Insurance Program Declaration” together with its payment / loan agreement to Arthur J. Gallagher.
4pm 1 October 2017 to 4pm 31 December 2017 Participating in fixture games sanctioned by QRL: Cover provided to those Players / Coaches who: • Were registered with a QRL Affiliated Club / Local League for the 2017 season. Training and participating in trial / non fixture games sanctioned by QRL: Cover provided to those Players / Coaches who: • Were registered with a QRL Affiliated Club / Local League for the 2017 season; or • Are registered with a QRL Affiliated Club / Local League for the 2018 season; or • Have been listed on a trial and train register with a QRL Affiliated Club / Local League for the 2018 season.
Important Information Please Note: A person who has reached the age of forty (40) years or is reaching that age during a football season, and desires to participate in a game of rugby league under these Rules, must lodge with his Player’s Agreement each year a Certificate or Report issued by a Registered Sports Physician or Medical Specialist in Queensland stating that the person does not have any apparent impediment, declared or otherwise, that would preclude his participation in a body contact sport. Please also note that the Public Liability and Player Accident insurance covers under the NRL Community Insurance Program which covers your club for all Rugby League activities does not extend to include non sanctioned Rugby League Carnivals or other ancillary sports such as Touch Football competitions. Arthur J. Gallagher has developed a policy specifically for One Off Rugby League Carnivals and other ancillary sports such as Touch Football competitions, which will protect your club for any incidents relating to these activities. Please note major Policy Exclusions of the Insurance Handbook.
QRL 2017 Insurance Declaration | Page 3
Queensland Rugby League 2017 Insurance Declaration Club Details General Details Full name of the Club (as per Incorporation Certificate) Are you registered for GST purposes?
Yes
No
What is your ABN? Postal Address of Club Postcode Club Grounds Address Postcode Club
President
Treasurer
Secretary
Name Email
Telephone (B/Hrs) Fax Mobile Has your Club applied for affiliation for the 2017 season and been accepted by the relevant Division? Yes
No
Division (Please circle)
South East
Central
Northern
What League does your club play in Club Activities Does your Club hold a liquor license, outside ‘QRL game day’?
Yes
No
If Yes, what are your trading hours?
Does your Club have poker machines?
Yes
No
If Yes, how many?
What is your Club’s annual turnover?
$
Does your Club operate another sport
Yes
No
If Yes, what type
Previous Public Liability Claims
Yes
No
If Yes, please attach details
Childminding / Playground
Yes
No
Public Gymnasium
Yes
No
Live Entertainment (Bands etc)
Yes
No
Dance Floor
Yes
No
After 1.00am Trading
Yes
No
Provide Outside Catering
Yes
No
Closed Circuit TV Monitoring installed
Yes
No
Do you hire out your club to third parties
Yes
No
Arthur J. Gallagher. NRL Whole of Game Program
(I.e. revenue prior to expenses)
If Yes, estimated income $
Property Insurance Renewal/Quote Request Declaration Property Sums Insured Material Damage Buildings
$
Contents
$
Stock
$
Lighting & Towers
$
Other
$
Description
Other
$
Description
Mobile Machinery (Tractors / Ride on Mowers etc) $
Description
Registered
Mobile Machinery
$
Yes
No
Mobile Machinery
$
Yes
No
Machinery Breakdown (Pumps, Motors & Compressors) Description Required $
Description
Required
Limit any one loss
$25,000
Yes
No
Deterioration of stock
$2,500
Yes
No
Electronic Equipment & Breakdown (Computers, Hardware & Software) $
Description
Required
Limit any one loss
$5,000
(Scoreboard limited to $10,000)
Yes
No
Data Restoration
$2,500
Yes
No
Increased cost of working
$2,500
Yes
No
Business Interruption Gross Profit
$
Payroll (if insured separately)
$
Other Insurances Does your Club take out any additional insurance cover than that provided via QRL / Arthur J. Gallagher? Yes
No
Type of Policy
If yes, please provide details below Due Date
Insurer
Broker
PLEASE NOTE: Completion of this section does not automatically effect insurance. If your changes are urgent, please contact us on 1800 SPORT 0 QRL 2017 Insurance Declaration | Page 5
Queensland Rugby League 2017 Insurance Declaration Cost per Team – PART A (Compulsory - if applicable) Stamp Duty Exempt (**Exemption Required)
Not Stamp Duty Exempt
Under 6
@ $ 62
or $ 65
=$
Under 7
@ $100
or $105
=$
Under 8
@ $100
or $105
=$
Under 9
@ $178
or $185
=$
Under 10
@ $178
or $185
=$
Under 11
@ $254
or $265
=$
Under 12
@ $254
or $265
=$
Under 13
@ $437
or $450
=$
Under 14
@ $437
or $450
=$
Under 15
@ $635
or $650
=$
Under 16
@ $736
or $755
=$
Under 17
@ $824
or $845
=$
Under 18
@ $908
or $930
=$
Grade
Number of Teams
Total Part A
Premium
$
Cost per Club Entity – PART B (Compulsory) Category Club Management Liability
Stamp Duty Exempt (**Exemption Required)
Not Stamp Duty Exempt
Total Part B
$315
$330
$315 or $330 (please circle)
** To qualify for the Stamp Duty Exempt Premium, you must provide a copy of your Stamp Duty Exemption Certificate each year. If you do not provide this certificate, the Stamp Duty Exempt premium, will not be accepted. To obtain certificate you must contact the Office of State Revenue. Details can be found at: https://www.business.qld.gov.au/industry/professional-financial/insurance-duty/calculating/exemptions
Arthur J. Gallagher. NRL Whole of Game Program
Cost per Team – PART C (Compulsory - if applicable) Stamp Duty Exempt (**Exemption Required)
Not Stamp Duty Exempt
Under 19
@ $1,920
or $1,950
=$
Under 20
@ $2,890
or $2,930
=$
Under 22
@ $2,890
or $2,930
=$
A Grade
@ $2,890
or $2,930
=$
B Grade
@ $2,890
or $2,930
=$
C Grade
@ $2,890
or $2,930
=$
Opens
@ $2,890
or $2,930
=$
Masters
@ $2,890
or $2,930
=$
Womens
@ $2,890
or $2,930
=$
Intrust Super Cup
@ $2,890
or $2,930
=$
FOGS Colts
@ $2,890
or $2,930
=$
Grade
Number of Teams
Total Part C
Premium
$
Loss of Income option – PART D PLEASE NOTE: Loss of income is not automatically included for senior teams / players. You can either take out these options by entering into the below table, or direct your teams / players to Arthur J Gallagher on 1800 SPORT 0 (1800 776 780), for an individual quote should your club elect not to take up this benefit on their behalf. Senior teams or Individual Player Loss of Income (Refer page 5-6 of the handbook)
Weekly Benefit
Premium
Team grade / Player Name:
$
Team grade / Player Name:
$
Team grade / Player Name:
$ Total Part D
$
Total cost of insurance Total Premium Payable (Part A, B, C, D):
$
QRL 2017 Insurance Declaration | Page 7
Queensland Rugby League 2017 Insurance Declaration Duty of Disclosure Before you enter into a contract of general insurance with an Insurer, you have a duty at law to disclose to the Insurer anything that you could be reasonably expected to know is relevant to the Insurer’s decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to the Insurer before you renew, extend, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of matter: • • • •
that diminishes the risk to be undertaken by the insurer; that is of common knowledge; that your insurer knows or, in the ordinary course of business ought to know; as to which compliance with your duty is waived by the insurer.
If you fail to comply with your duty of disclosure, the Insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the Insurer may also have the option of avoiding the contract from its beginning.
Declaration & Acknowledgments I/We declare and acknowledge that I/We: • have not suppressed, misrepresented or misstated any material information within my knowledge likely to affect the Insurers decision as to my eligibility for insurance and the answers given in the Proposal and the completed quote questionnaire are in every respect true and correct. • have received, read and fully understand the details contained in the 2017 NRL Community Insurance Program Handbook. Furthermore, I acknowledge the property insurance program is an optional policy and that cover will only commence upon written acceptance of a formal quotation provided by Arthur J. Gallagher. • acknowledge that the public liability insurance component of the insurance program is intended to provide cover for “normal” activities of Rugby League. Activities outside of Rugby League including but not limited to fundraising and social activities may not be covered under this policy and should be referred to Arthur J. Gallagher for clarification. • subject to the Insurance (Agents and Brokers) Act, if this Proposal is accepted by the Insurer, the Proposal, the Policy and Schedule issued shall constitute the entire agreement between you and us, and shall supersede any prior representations or warranties.
Signature of President, Treasurer or Secretary Name of President, Treasurer or Secretary
Date
/
/
Arthur J. Gallagher. NRL Whole of Game Program
Important Checklist General Has the Duty of Disclosure been signed and dated? Have you attached copies of any contractual Agreements signed by the Club / Local League? If you are claiming Stamp Duty Exempt status have you attached a copy of your certificate from the Office of State Revenue?
Yes
No
Yes
No
Yes
No
Payment Options (tick) 1.
Cheque for $
made payable to “Arthur J. Gallagher” is attached
2. Direct Debit Option – if you wish to pay by an on-line direct debit transfer, please forward your completed declaration. On receipt we will email your invoice back to you, with your own clubs dedicated Direct Debit details for easy transfer 3. Premium Funding – if you wish to Fund please contact Arthur J. Gallagher on 1800 SPORT 0 to obtain a Funding quote, as per below process.
NOTE: If you would like a funding quotation for monthly instalments please follow these steps: 1. Phone 1800 SPORT 0 (1800 776 780) and advise that you are a “QRL Club requesting a Premium Funding Quotation”. 2. Have your total team numbers ready. 3. A quote & contract will then be emailed to you 4. If you accept the funding contract, simply complete, sign and return directly to Arthur J. Gallagher, together with your completed 2017 QRL Insurance Program Declaration.
REMINDER: Completed documents must be forwarded directly to Arthur J. Gallagher, by no later than the 28 February 2017.
Please return the completed Declaration together with your Payment / Loan Agreement directly to AJG Sport, GPO Box 1113, BRISBANE QLD 4001 QRL 2017 Insurance Declaration | Page 9
Queensland Rugby League 2017 Insurance Declaration Contacts – Arthur J. Gallagher Branch
Sport, Leisure and Recreation team Level 2, 601 Coronation Drive, TOOWONG QLD 4066 Postal Address:
GPO Box 1113 BRISBANE QLD 4001
Team Leader
Assistant Account Executive
Assistant Account Executive
Arthur J. Gallagher. NRL Whole of Game Program
Phone:
1800 SPORT 0 (1800 776 780)
Fax:
07 3367 5100
Terry Berryman Phone:
(07) 3367 5010
Mobile:
0438 596 939
E-mail:
[email protected]
Julian Jemmott Phone:
(07) 3367 5146
E-mail:
[email protected]
Bryce Stevens Phone:
(07) 3367 5072
E-mail:
[email protected]
QRL 2017 Insurance Declaration | Page 11
Arthur J. Gallagher Insurance Brokers. AFSL 238312. To the extent that any material in this brochure may be considered advice, it may only be considered general advice as it does not take into account your personal objectives, needs or financial situation. Arthur J. Gallagher urges you to read the relevant policy wording and consider whether any products are appropriate for your situation before making a decision to acquire insurance. Ref 1342-Dec16
1800 SPORT 0 (1800 776 780)
