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Graybrook
01245 321 185
Home
Meet the Team
Links
Testimonials
News
Contact Us
Terms of Business
Privacy Notice
Business Insurance
Business Insurance
Management Liability
Equipment Insurance
Professional Bodies
Professional Bodies, Charities,
Trade Unions & Associations
Education
Prospect Members
NAHT & NAHT Edge Members
Educational Consultants
Paramedics
College of Paramedics
HPA Members
Paramedic Insurance
Orthoptics
BIOS Members
Equipment Insurance
Physiotherapy
Practice Insurance
Business Liability Insurance
Equipment Insurance
CSP Members
Physio First Members
AACP Members
ACPAT Members
MACP Members
CSP Professional Networks
CSP Sports Massage
ISCP Members
Top-Up
Locum Cover
Massage & Fitness
SMA Members
Sports Massage
CSP Sports Massage
BASRaT Members Insurance Benefits
BASRaT Top Up
BASRaT Student Sports Massage
UKSCA Members
Intrinsic Biomechanics Association
Move It or Lose It Trainers
Equipment Insurance
Other Therapies
Manual Handling
NBE Members
Complementary Therapy
Equipment Insurance
Criminal Prosecution
Criminal Defence Costs
Sports Massage Professional & Public Liability Insurance Application Form
Date: 21/02/2019
Step 1
Step 2
Step 3
Step 4
Your Information
Title
Mr
Mrs
Miss
Ms
Full name of Proposer
Are you qualified?
- Select Option -
No
Yes
If no please provide training provider
Business Name (if applicable) – If a Limited Company please state company name & full names of all Directors and if a partnership please state full names of all partners
Correspondance Address
Postcode
Contact Telephone Number
Contact Email Address
In the next 12 months will you be working outside of the UK?
- Select Option -
No
Yes
If Yes please confirm the number of days you will be working outside the UK
Annual Income from the Work to be Insured (numbers only)
£
Do you offer training to others?
- Select Option -
No
Yes
If Yes please state details of the training courses provided
The policy provides cover for civil liability arising whilst practitioners are working temporarily anywhere in the world, providing they are ordinarily resident in the United Kingdom and work within the scope of their qualifications. No claims are covered for any work the practitioner is not qualified to perform, or undertaken in the U.S.A. or Canada if you they have any assets there.
Please indicate by ticking the appropriate boxes the therapies for which cover is required.
Band 1
Sports Massage (Qualified)
Acupressure
Aromatherapy
Baby Massage
Deep Bodywork Massage
Facial Massage
Indian Head Massage
No Hands Massage
Pilates
Reflexology
Reiki
Sports & Remedial Massage
Swedish Massage
Yoga/Baby Yoga
Manual Lymphatic Drainage Massage
Holistic Massage
Massage in Pregnancy
Sports Massage (Student)
Band 2
Electro Therapy & Ultrasound
Fitness Training & Classes
Hopi Ear
Hot Stone
Personal Training
Sports Therapy & Rehabilitation
Strength & Conditioning
Kinesio Taping
Band 3
Acupuncture
Dry Needling
Please specify any activities which are not listed above for which cover is required
First Aid and Related Activities
Do you attend outside events to offer Sports Massage, which may include ancillary First Aid?
- Select Option -
No
Yes
Do you attend to offer First Aid ONLY?
- Select Option -
No
Yes
If you have answered Yes to either of the above, please state:
Types of event attended
Frequency
First Aid Qualification
Do you offer:
Wound Management
- Select Option -
No
Yes
Suturing
- Select Option -
No
Yes
Sports Trauma Management
- Select Option -
No
Yes
If yes, please note that the policy is only intended to cover all the above activities as ‘First Response’ only, and you must provide copies of your qualification certificates as evidence of competency. If you provide services beyond First Response, please give details:
Limits of Indemnity Options
All policies have £5,000,000 Professional Indemnity Insurance and £5,000,000 Public Liability Insurance as standard If additional activities/therapies are to be insured, or cover for training other trainers is required, then a separate quotation will be issued
Please tick the therapy band required
Sports Therapy UK Student at an annual premium of £29.84
Student in Sports Massage at an annual premium of £35.70
Band 1 Therapies at an annual premium of £83.65
Band 2 Therapies at an annual premium of £146.80
Band 3 Therapies at an annual premium of £207.63
If more than one therapy is to be insured, the premium for the higher rated activity will apply. Please note that certain restrictions may apply to specific activities - full details are available on request
Do you require Employers Liability Insurance?
- Select Option -
No
Yes
If you require Employers Liability Cover (£10,000,000 Limit) please tick one of the following two options(please note this cover can not be taken in isolation
1-3 Employees at an additional premium of £114.48
4-6 Employees at an additional premium of £156.95
If Employers Liability is selected please provide your unique Employers Reference Number below (provided by HM Revenue & Customs when setting up PAYE & NIC contributions)
The Employers PAYE reference number is usually in the format of either NNN/Aannnnn or NNN/Annnnn, where N/n is a number and A/a is a letter (e.g. 012/Ab34567)
Total Premium Payable
The amount payable is inclusive of insurance premium tax, brokerage and all administration fees, details of which are available on request.
If you are sending payment by Bank Transfer (BAC's) or Cheque please indicate here, otherwise we will contact you regarding payment once your form has been received.
Bank Transfer
Cheque
Please Call Me
If you have selected Bank Transfer or Cheque, please send payment as soon as possible. We will require your payment before we can process your paperwork.
BACS payments should be made to Graybrook Insurance Brokers Limited, Sort Code 20-19-95, Account Number 20402419, and please use your name as the payment reference
Cheques should be made payable to Graybrook Insurance Brokers Limited and sent to 'Graybrook Insurance Brokers Limited, 8 Chandlers Way, South Woodham Ferrers, Essex CM3 5TB'
Disclosure of Material Facts Declaration
Please answer the following:
(a) To the best of your knowledge and belief have there been any claims made against you in respect of any of the covers now proposed?
- Select Option -
No
Yes
(b) Are you aware of any existing circumstances which may give rise to a claim?
- Select Option -
No
Yes
(c) Do you undertake any work in the USA, or its territories and possessions, or in Canada?
- Select Option -
No
Yes
(d) Do you provide treatment to any Professional Footballer?
- Select Option -
No
Yes
(e) Has any Insurer declined a proposal or refused to renew insurance?
- Select Option -
No
Yes
(f) Has any Director, Principal, Partner or Employee Been declared bankrupt, been the subject of any bankruptcy proceedings or any form of insolvency or winding up procedures (including administrative receivership), OR Been the subject of a recovery action by HM Revenue & Customs, OR Been prosecuted, served prohibition or served an improvement order or notice under Health and Safety legislation or Environmental protection legislation, OR Been disqualified from being a company director, OR Been the subject of a County Court or High Court judgement, OR Been a director of a company that has received a County Court or High Court judgement against it?
- Select Option -
No
Yes
If you have answered “Yes” to any of the above questions, please provide details
Policy Start Date
Please note that cover will not commence until this form has been received and accepted by Graybrook Insurance Brokers Limited (unless otherwise agreed). The policy will run for 12 months from the agreed date.
Please acknowledge that you have read and understood Graybrook Insurance Brokers Terms of Business Agreement and Privacy Notice
Yes
Please acknowledge that you have read and understood the policy terms and conditions
Yes
Please acknowledge acceptance of the following:
I declare that to the best of my knowledge or belief the particulars and statements given in this proposal and any other information provided in connection with this proposal are true and complete and this proposal, declaration and information shall be the basis of the contract between myself and the Insurer. I consent to the processing of any sensitive personal data in order to administer and underwrite this policy. I agree to accept the insurer’s standard form of policy and endorsements for this insurance. I confirm that all persons carrying out activities in accordance with the Business as defined above are suitably qualified to do so.
Yes
Important Information
Personal Data
The insurer for policies underwriting this scheme is AXA Insurance UK plc (AXA). The scheme is administered on their behalf by Graybrook Insurance Brokers Limited.
To arrange and administer your policy AXA and Graybrook Insurance Brokers Limited will hold and use information supplied by you, in accordance with U.K. Data Protection Laws and General Data Protection Regulation (GDPR). Full information and your rights about the personal data we collect and process can be found in our Privacy Notice which is available on request and online at www.graybrook.co.uk. A copy of the Privacy Notice will also be included in your quotation/renewal pack.
Graybrook Insurance Brokers Limited would also like to send you details from time to time of their other related insurance products/services which may be of interest and benefit to you. Please select if you wish to receive such details by:-
Post
Email
Telephone
Unless you select one of these options we will not be able to send information on any of our other insurance policies or services.
We will not sell or pass your information to other organisations for marketing purposes.
CUE - Insurers pass information to the Claims and Underwriting Exchange register, run by Insurance Database Services Limited (IDS Ltd). The aim is to help us to check information provided and also to prevent fraudulent claims. When we deal with your request for insurance, we may search the register. When you tell us about an incident which may or may not give rise to a claim, we will pass information relating to it to the register. You can ask for more information about this.
IPT - Insurance Premium Tax
The Finance Act 1994 requires us to levy Insurance Premium Tax at the prevailing rate on insurance premiums. For further information, please ask us.
LAW APPLICABLE
The parties to the policy have the right to choose the law applicable to the Policy. Unless the parties agree otherwise English Law shall apply
This Scheme is administered by:
Graybrook Insurance Brokers Limited, 8 Chandlers Way, South Woodham Ferrers, Essex, CM3 5TB
Web: www.graybrook.co.uk - Email: enquiry@graybrook.co.uk - Tel: 01245321185 - Fax: 01245 322240
Graybrook Insurance Brokers Limited is Authorised and regulated by the Financial Conduct Authority. Registered No. 595238
This scheme is underwritten by:
AXA Insurance UK plc
AXA Insurance UK plc is authorised by the Prudential Regulation Authority and regulated by the
Financial Conduct Authority and the Prudential Regulation Authority.
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