01245 321 185

Sports Massage Professional & Public Liability Insurance Application Form

Date: 19/08/2019

Your Information
£
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.
First Aid and Related Activities
If you have answered Yes to either of the above, please state:
Do you offer:
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
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
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)
The amount payable is inclusive of insurance premium tax, brokerage and all administration fees, details of which are available on request.
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 Hallam, Sort Code 20-19-95, Account Number 20402419, and please use your name as the payment reference

Cheques should be made payable to Graybrook Hallam and sent to 'Graybrook Hallam, 8 Chandlers Way, South Woodham Ferrers, Essex CM3 5TB'
Disclosure of Material Facts Declaration
Please answer the following:

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 acceptance of the following:
Important Information

Personal Data
The insurer for policies underwriting this scheme is AXA Insurance UK plc (AXA). The scheme is administered on their behalf byGraybrook Hallam.

To arrange and administer your policy AXA 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.
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 Hallam, 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 Hallam 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.