Sportscover Directors and Officers Insurance Quote Request

*Contact Name:

*Organisation Name:

*Postal Address:

*Suburb/Town:

*Postcode/Zipcode::

*State/County/Province:

*Country:

Phone no:

Fax no:

Email Address:

*Sport:

*Period of Insurance:

*Amount of Insurance required per policy period $:

*(A) Annual Turnover $:

*(B) Total Assets $:

*(C) Total Net Shareholders Funds $ :

*(D) At Last Balance Date (Give Date) :

*(i) Profit(Loss) :

*(ii) Accumulated Losses :

Date Club/Association Established :

Total number of financial members:

Committee Personnel :
List name and position of all committee members and their position

Complete list of Associated Clubs:

(Note: Cover does not extend to associated clubs)

Name, Qualifications and Duration of all Clubs/Association Directors:

(A) List name, position and club/association affiliation of all past and present Directors/Officers who hold or have held outside directors solely for the purpose of representing the Club/Association including your auditor.

(B) Provide details of any existing coverage carried by these Clubs/Associations.

(A) Has there been any material change in the financial condition of the Club/Association or its associates or any other matters considered material to the acceptance of this proposal since the last annual report, or since production of the financial data provided with this proposal?

(B) Was the Club/Association trading profitably at the close of the calender month?

Does the Club/Association or its associates conduct sport in the United States of America? If yes, supply details of the nature and extent of its activities, including percentages of total turnover so derived.

Has there been or is there any claim against any person for Insurance in their capacity of either Director or Officer of the above Club/Association or any other Club/Association? If yes, please give comprehensive details. (By way of attachment if necessary)

Has any person proposed for insurance ever been subject to disciplinary action, been fined or penalised or been subject to an enquiry in their capacity as a Director/Officer? If yes, please give comprehensive details.(By way of attachment if necessary)

Does any Director or Officer to be covered by this insurance, after specific injury of management and staff, have knowledge or information of any incident, act, error or omission which may give rise to a claim under the proposed policy? If yes, please give comprehensive details.

(Note: if such knowledge or information exists, any claim or action arising there from is excluded from this proposed coverage.)

(A) Name of Insurer:

Details of existing or previous Directors and Officers legal liability Insurance

(C) Sum Insured:

Has any insurer refused, cancelled or increased the premium of any insurance of this nature.

Is the Club/Association currently subject to any takeover attempt or has the Club/Association publicly revealed its intention to merge with or takeover any other Club/Association? If yes, please give details.

Has the Club/Association merged with/taken over any other entity since the date of its last annual report? If yes, please give details.

Has there ever been, or is there now pending, any prosecution of the Club/Association or its associates under any statue legislation, particularly under any companies code or trade practices act? If yes, please give details.

*Have you had any claims in the past 3 years?

If you clicked "YES" in the
previous question, please
give details of claims:

Any other Relevant Information:

*Name of Agent requesting Quote: