International Tae Kwon Do Council Club Insurance

I N T E R N A T I O N A L T A E K W O N D O C O U N C I L C L U B I N S U R A N C E P R O P O S A L F O R M

You have a duty to provide Insurers with a Fair Presentation of your Risk and to disclose all Material Information. Material Information is that likely to influence acceptance or assessment of the risk by Insurers. If you are in doubt as to whether information is material or not, please discloses it. It is essential you provide Insurers with ALL MATERIAL FACTS.

WE RESERVE THE RIGHT TO DECLINE ANY PROPOSAL. NO COVER IS IN FORCE UNTIL ACCEPTANCE IS CONFIRMED BY US.

DETAILS: Contact Name: Telephone Number: Email Address:

Name of Martial Arts Club/Association:

Please list all Martial Arts/Disciplines Instructed: (Note the use of any live/sharp weapon is excluded). Address:

Post Code:

Full details of Instructor Qualifications/Grades:

The ITC also requires that copies of the Degree Certificate Instructor’s Certificate HSE form following should be attached to this First Aid Certificate DBS application. Ecard Number: (Contact us if anything is unavailable)

PUBLIC LIABILITY INSURANCE: Limit of Indemnity Required: £5,000,000

Number of Instructors to be Insured:

Name/s of Instructor/s to be Insured & their 1. Belt Levels: 2. 3. 4. 5. (continue as necessary)

Total Number of Student Members:

A completed Student detail list should be kept by your selves with all Membership, student insurance number, contact and emergency details.

Location/s where activities are undertaken:

St Benedicts Limited Tel: 01603 626904 Fax: 01603 628174; Website: www.stbensinsurance.co.uk Authorised & Regulated by the Financial Conduct Authority for non investment insurances (FCA Register No. 307673) Registered in England & Wales No. 298926

CLAIMS HISTORY: Date of Incident Reserve/Settlement Details of Incident/s £

ANY ADDITIONAL INFORMATION:

DECLARATION:

DATA PROTECTION ACT CLAUSES i. Proposer’s consent clause, NMA 2866, for inclusion within Proposal Forms for private individuals: DATA PROTECTION ACT 1998 By signing this Proposal Form I/We hereby consent to any information you may have about me/us being processed by you for the purpose of providing insurance and claims handling which may necessitate your providing such information to third parties. To the best of my knowledge and belief the information provided in connection with this declaration, whether in my own hand or not, is true and I have not withheld any material facts. (N.B. a Material fact is one likely to influence acceptance or assessment of the risk by Insurers. If you are in doubt as to whether a fact is material or not, please discloses it). I understand that signing this declaration does not bind me to complete, or Insurers to accept, this insurance.

SIGNATURE OF PROPOSER:

POSITION:

Please return this form to; office @international-taekwondo-council.com

or ITC 42 Baker House Grove Great Barr Birmingham B43 5HX

St Benedicts Limited Tel: 01603 626904 Fax: 01603 628174; Website: www.stbensinsurance.co.uk Authorised & Regulated by the Financial Conduct Authority for non investment insurances (FCA Register No. 307673) Registered in England & Wales No. 298926