01245 321185

Sports Massage Professional & Public Liability Insurance Application Form

Date: 18/09/2020

Your Information

Title

Mr	Mrs	Miss
Ms	Dr

Full name of Proposer (If a Limited Company please state registered name & Companies House registration number, and if a partnership please state the full names of all partners)

What is the trading name of your business?

Please provide details of any previous names the business has traded under

Are you a Member of any Association?

If Yes, please state the Name of the Association, Membership Category (Full/Student), Membership No:

Date the business was established

Turnover Projection for next 12 Months

Correspondence Address

Postcode

Contact Name

Contact Telephone Number

Contact E-mail Address

Your Website Address

Activities you wish to Insure You must accurately describe and list below all activities for which you are qualified to undertake and for which insurance is required. You must also demonstrate you have successfully completed an appropriate and recognised course if requested for each activity listed and insert below the percentage of your total annual income against each activity declared

Please state the activities to be Insured and the percentage you wish to cover:

Do you undertake injection therapy? If Yes, please state in the box below:- (a) Whether all therapists involved in injection therapy have successfully completed an accredited relevant injection therapy course (b) The type of injection therapies undertaken (c) Whether any Spinal Injections are undertaken? (d) The approximate percentage Injection Therapy comprises to your annual turnover

Important Note: No cover is available for Injection of Lipogems and Ultrasound Guided Stem Cell Injections

Do you undertake Acupuncture or Dry Needling treatments? If Yes, please state in the box below:- (a) Whether all therapists have successfully completed a Nationally Accredited Foundation Course approved or accredited by AACP (Acupuncture Association of Chartered Physiotherapists) or equivalent and registered with any Local Authority where required? (b) Details of any Acupuncture undertaken outside the scope of physiotherapy practice (c) The approximate percentage of your annual turnover

Important Note: No cover is available for acupuncture related to fertility treatment when undertaken by Physiotherapists

*When Doctors or Nurses are declared, full details of their activities must be submitted before cover can be agreed

Doctors - PAYE *

Doctors - Self-employed *

Nurses - PAYE *

Nurses - Self-employed *

Surgeons - PAYE

Surgeons - Self-employed

Acupuncturists - PAYE

Acupuncturists - Self-employed

Animal Physiotherapists (ACPAT) - PAYE

Animal Physiotherapists (ACPAT) - Self-employed

Biomechanics Coaches - PAYE

Biomechanics Coaches - Self-employed

Chiropractors - PAYE

Chiropractors - Self-employed

Osteopaths - PAYE

Osteopaths - Self-employed

Manual Handling - PAYE

Manual Handling - Self-employed

Manual Handling (National Back Exchange) - PAYE

Manual Handling (National Back Exchange) - Self-employed

Move it or Lose it Therapists - PAYE

Move it or Lose it Therapists - Self-employed

Physiotherapists - PAYE

Physiotherapists - Self-employed

Sports Massage - PAYE

Sports Massage - Self-employed

Strength & Conditioning - PAYE

Strength & Conditioning - Self-employed

Occupational Therapists - PAYE

Occupational Therapists - Self-employed

All Other Therapists/Fitness Professionals (please state) - PAYE

All Other Therapists/Fitness Professionals (please state) - Self-employed

Clerical/Administrators - PAYE

Clerical/Administrators - Self-employed

All Others (please state) - PAYE

All Others (please state) - Self-employed

It is a condition of this insurance that all self-employed practitioners and sub-contractors engaged by your business must maintain Medical & Public Liability Insurance in their own name to the same limit of indemnity as you select for your own business. All therapists, whether employed or self-employed must be suitably qualified and maintain registration with HCPC or other statutory regulator where required.

Limits of Indemnity and Employers' Liability

The standard limit of indemnity is £5,000,000, if a higher limit is required please contact us.

Do you require Employers Liability Insurance

This is an option you should consider if you engage employees, self-employed persons, volunteers (including students on work experience)
for whom you may be liable for any work-related illnesses or injuries.

If Employers Liability Insurance is required, please confirm the total number of Employees (including Directors) and Self- Employed persons for whom you are responsible

If Employers Liability Insurance selected, you must provide the following information. Employers PAYE Reference Number The Employers PAYE reference is usually a unique reference comprising letters and numbers (e.g. 012/AB34567)

Do you attend outside events to offer Sports Massage, which may include ancillary FirstAid?

Do you attend to offer First Aid ONLY?

If you have answered Yes to either the above, please state:

Types of event attended

Frequency

First Aid Qualification (We will require a copy of the certification)

Do you offer Wound Management?

Do you offer Suturing?

Do you offer Sports Trauma Management?

If yes, please note that the policy is only intended to cover all the above activities as ‘First Response’ only.

Disclosure of Fair Presentation

Your Duty of Disclosure
IMPORTANT NOTICE CONCERNING YOUR DUTY TO MAKE A FAIR PRESENTATION OF THE RISK
Before your insurance policy takes effect, you have a duty to make a fair presentation of the risks to be insured under your insurance policy. A fair presentation of the risk is one which discloses to the Insurer every material circumstance which you know of or ought to know of; or gives the Insurer sufficient information to put the Insurer on notice that they will need to make further enquiries for the purpose of revealing those material circumstances, which makes that disclosure referred to above in a manner which is reasonably clear and accessible to the Insurer; and in which every material representation as to a matter of fact is substantially correct, and every material representation as to a matter of expectation or belief is made in good faith.

A material circumstance is one that would influence the Insurer's decision as to whether or not to agree to insure you and, if so, the terms of that insurance. If you are in any doubt as to whether a circumstance is material, you should disclose it to the Insurer.

Please answer the following:

a) Have there been any claims made against you or any director, principal, employee or any other person engaged by you or any previous company in respect of any of the covers now proposed and are you aware after enquiry of any circumstances that could give rise to a claim?

b) Do you or are you likely to undertake work in Australia or North America including Canada?

c) Do you or are you likely to undertake any work elsewhere outside of the U.K. for more than 90 days a year? Please be aware this policy contains significant restrictions relating to activities undertaken outside of the United Kingdom

d) Do you provide treatment to any Professional Footballer? Please be aware this policy contains significant exclusions relating to the treatment of Professional Footballers

e) Have you or any Partner, Director, Employee or other persons engaged by you ever been the subject of a fitness to practice or disciplinary hearings or criminal prosecutions (excluding motoring convictions)?

f) Have you or any partner, director or employee been refused insurance or had special terms imposed?

If you have answered “Yes” to any of the above questions, please provide details

h) Do you engage self-employed persons or sub-contractors?

Policy Start Date

If you have answered “Yes” please confirm

(i) You check at least annually that all regulated Healthcare Professionals are registered withHCPC or other regulatory body where required

(ii) You check they maintain Professional & Public Liability Insurance up to the same limit as your Policy

i) Have you previously held Medical & Professional Liability Insurance?

If Yes, please provide the following details

Insurer

Retroactive Date

Policy & Certificate Number

Expiry Date

g) Have you or any Partner, Director, Employee or any other person engaged by you either been declared bankrupt, disqualified from holding office or had a County Court Judgement awarded against them?

When do you wish this Policy to start?

Important Notes:
• This policy is issued on an OCCURRENCE basis which only covers claims arising from activities undertaken during the currency of the policy.

• Cover will not commence until this application has been approved and a Quotation issued and accepted.

• Policies will run for 12 months from the agreed start date.

• No activities undertaken prior to commencement of the policy is insured unless agreed and noted in the Retroactive Endorsement. (Retroactive cover may be available subject to evidence of previous and continuous insurance)

Please acknowledge that you have read and understood the policy terms and conditions

Yes

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

I/We also confirm that the undersigned is authorised to act for and on behalf of all persons who may be entitled to indemnity under the policy to which this declaration relates and I/We complete this declaration on their behalf.

Yes

Name of Proposed Person

Position of Proposed Person

Important Information Personal Data The insurer for policies underwriting this scheme is RSA Insurance Group plc. (RSA). The scheme is administered on their behalf by Graybrook Hallam. To arrange and administer your policy RSA and Graybrook Hallam 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 Hallam 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:-

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.

This scheme is underwritten by Royal & Sun Alliance Insurance plc and arranged by Graybrook Hallam 8 Chandlers Way, South Woodham Ferrers, Essex CM3 5TB Tel: 01245 321185 Email: enquiry@graybrook.co.uk Royal & Sun Alliance plc (No. 93792) Registered in England and Wales at St Mark's Court, Chart Way, Horsham, West Sussex, RH12 1XL.Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority Graybrook Hallam is a Trading Name of James Hallam Limited which is authorised and regulated by the Financial Conduct Authority (FCA) James Hallam Limited is registered in England. Registered number 1632840. Registered Office: 156 South Street, Dorking, Surrey RH4 2HF.