QUEENSLAND RUGBY LEAGUE 2018 INSURANCE DECLARATION - Name of club: ajg.com.au/qrl - Amazon AWS
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ajg.com.au/qrl
NATIONAL RUGBY LEAGUE | WHOLE OF GAME PROGRAM
QUEENSLAND RUGBY LEAGUE 2018
INSURANCE DECLARATION
Name of club:
To be completed and returned directly to Gallagher, by no later than 28 February 2018.
AJG001814-1117
Queensland Rugby League
2018 Insurance Declaration
Arthur J. Gallagher Co (Aus) Limited
34 005 543 920
25 Main Street Beenleigh QLD 4207
PO Box 302
Beenleigh QLD 4207
T: 1800 SPORT 0 (1800 776 780)
F: (07) 3367 5100
www.ajg.com.au/qrl
Attention: Committee Members
QRL Affiliated Clubs and Local Leagues
Dear Committee Members,
Re: 2018 Whole of Game Insurance Program
It is compulsory that each Affiliated Club and Local League (where applicable) effects for its Teams, the minimum level
of Insurance cover by 28 February 2018. Please note a Loss of Income Weekly Benefit of $300 per week, is now built
into all U19’s, U20’s and Senior teams coverage. Should you require increased cover, top up options are available. Club
Management Liability (Part B. page 6) is compulsory and must be selected.
The level of benefits provided by the Program are not “comprehensive” and as such the QRL and Gallagher encourage all
participants to take out Private Health, Life and Income Protection Insurance according to their own individual circumstances.
It must be clearly understood that after being informed of the level of cover taken out by a Club or Local League, it is an
Individual’s responsibility to ensure that he / she has adequate Insurance cover for his / her needs.
It is essential that each Club and Local League Executive advise all Players, Officials and Volunteers associated with its
Teams of this level of Insurance cover and any additional cover it has taken out. To assist in advising all participants of their
minimum insurance cover we have produced a “Quick Guide to the 2018 QRL Community Insurance Program” that must
be distributed to all participants by Clubs and Local Leagues (where applicable).
Your 2017 cover will expire at 4pm on 31 December 2017. Gallagher will arrange for the minimum 2018 cover to take
effect from 4pm 31 December 2017 for all Affiliated QRL Clubs and Local Leagues.
You must complete this “Insurance Program Declaration” and return directly to Gallagher, by 28 February 2018
together with your premium payment / loan agreement and a copy of any contractual agreements entered into by
the organisation.
Yours sincerely Endorsed by
Terry Berryman Rob Moore
Team Leader Managing Director
Gallagher Sport QLD Rugby League
Gallagher. NRL Whole of Game ProgramImportant Dates and Information
4pm 31 December 2017 to 4pm 28 February 2018
Training and participating in trial / non fixture games sanctioned by QRL: Cover provided to those Players / Coaches who:
• Were registered with a QRL Affiliated Club / Local League for the 2017 season; or
• Are registered with a QRL Affiliated Club / Local League for the 2018 season; or
• Have listed on a trial and train register with a QRL Affiliated Club / Local League for the 2018 season.
4pm 28 February 2018 to 4pm 1 October 2018
No cover whatsoever unless Players / Coaches:
• Are registered with a QRL Affiliated Club / Local League for the 2018 season; and
• The Club / Local League has submitted its completed “Insurance Program Declaration” together with its payment /
loan agreement to Gallagher.
4pm 1 October 2018 to 4pm 31 December 2018
Participating in fixture games sanctioned by QRL: Cover provided to those Players / Coaches who:
• Were registered with a QRL Affiliated Club / Local League for the 2018 season.
Training and participating in trial / non fixture games sanctioned by QRL: Cover provided to those Players / Coaches who:
• Were registered with a QRL Affiliated Club / Local League for the 2018 season; or
• Are registered with a QRL Affiliated Club / Local League for the 2019 season; or
• Have been listed on a trial and train register with a QRL Affiliated Club / Local League for the 2019 season.
Important Information
Please Note: A person who has reached the age of forty (40) years or is reaching that age during a football season,
and desires to participate in a game of rugby league under these Rules, must lodge with his Player’s Agreement each
year a Certificate or Report issued by a Registered Sports Physician or Medical Specialist in Queensland stating that the
person does not have any apparent impediment, declared or otherwise, that would preclude his participation in a body
contact sport.
Please also note that the Public Liability and Player Accident insurance covers under the NRL Community Insurance
Program which covers your club for all Rugby League activities does not extend to include non sanctioned Rugby League
Carnivals or other ancillary sports such as Touch Football competitions. Gallagher has developed a policy specifically for
One Off Rugby League Carnivals and other ancillary sports such as Touch Football competitions, which will protect your
club for any incidents relating to these activities.
Please note major Policy Exclusions of the Insurance Handbook.
QRL 2018 Insurance Declaration | Page 3Queensland Rugby League
2018 Insurance Declaration
Club Details
General Details
Full name of the Club (as per Incorporation Certificate)
Are you registered for GST purposes? Yes No
What is your ABN?
Postal Address of Club
Postcode
Club Grounds Address
Postcode
Club President Treasurer Secretary
Name
Email
Telephone (B/Hrs)
Fax
Mobile
Has your Club applied for affiliation for the 2018 season and been accepted by the relevant Division?
Yes No
Division (Please circle) South East Central Northern ISC
What League does your club play in
Club Activities
If Yes, what are your trading
Does your Club hold a liquor license, outside ‘QRL game day’? Yes No
hours?
Does your Club have poker machines? Yes No If Yes, how many?
What is your Club’s annual turnover? $ (I.e. revenue prior to expenses)
Does your Club operate another sport Yes No If Yes, what type
Previous Public Liability Claims Yes No If Yes, please attach details
Childminding / Playground Yes No
Public Gymnasium Yes No
Live Entertainment (Bands etc) Yes No
Dance Floor Yes No
After 1.00am Trading Yes No
Provide Outside Catering Yes No
Closed Circuit TV Monitoring installed Yes No
If Yes, estimated income
Do you hire out your club to third parties Yes No
$
Gallagher. NRL Whole of Game ProgramProperty Insurance Renewal/Quote Request Declaration
Property Sums Insured
Material Damage
Buildings $
Contents $
Stock $
Lighting & Towers $
Other $ Description
Other $ Description
Mobile Machinery (Tractors / Ride on Mowers etc)
$ Description Registered
Mobile Machinery $ Yes No
Mobile Machinery $ Yes No
Equipment Breakdown (Computers, Servers, Pumps, Fridges, Air Con & Compressors) Description Required
$ Description Required
Limit any one loss $40,000 Yes No
Deterioration of stock $2,500 Yes No
Data Restoration $2,500 Yes No
Increased cost of working $2,500 Yes No
Business Interruption
Gross Profit $
Payroll
$
(if insured separately)
Other Insurances
Does your Club take out any additional insurance cover than that provided via QRL / Gallagher?
Yes No If yes, please provide details below
Type of Policy Due Date Insurer Broker
PLEASE NOTE: Completion of this section does not automatically effect insurance. If your changes are urgent, please
contact us on 1800 SPORT 0
QRL 2018 Insurance Declaration | Page 5Queensland Rugby League
2018 Insurance Declaration
Cost per Team – PART A (Compulsory - if applicable)
Stamp Duty Exempt Not Stamp Duty
Grade Number of Teams Premium
(**Exemption Required) Exempt
Under 6 @ $ 58 or $ 60 =$
Under 7 @ $98 or $100 =$
Under 8 @ $98 or $100 =$
Under 9 @ $178 or $190 =$
Under 10 @ $178 or $190 =$
Under 11 @ $254 or $270 =$
Under 12 @ $254 or $270 =$
Under 13 @ $437 or $450 =$
Under 14 @ $437 or $450 =$
Under 15 @ $635 or $650 =$
Under 16 @ $736 or $760 =$
Under 17 @ $824 or $850 =$
Under 18 @ $1,078 or $1,100 =$
Total Part A $
Cost per Club Entity – PART B (Compulsory)
Stamp Duty Exempt Not Stamp Duty
Category Total Part B
(**Exemption Required) Exempt
$350 or $370
Club Management Liability $350 $370
(please circle)
** To qualify for the Stamp Duty Exempt Premium, you must provide a copy of your Stamp Duty Exemption Certificate each
year. If you do not provide this certificate, the Stamp Duty Exempt premium, will not be accepted. To obtain certificate you
must contact the Office of State Revenue.
Details can be found at:
https://www.business.qld.gov.au/industry/professional-financial/insurance-duty/calculating/exemptions
Gallagher. NRL Whole of Game ProgramCost per Team – PART C (Compulsory - if applicable)
Stamp Duty Exempt Not Stamp Duty
Grade Number of Teams Premium
(**Exemption Required) Exempt
Under 19 @ $2,372 or $2,410 =$
Under 20 @ $3,624 or $3,660 =$
Under 22 @ $3,624 or $3,660 =$
A Grade @ $3,624 or $3,660 =$
B Grade @ $3,624 or $3,660 =$
C Grade @ $3,624 or $3,660 =$
Opens @ $3,624 or $3,660 =$
Masters @ $3,624 or $3,660 =$
Womens @ $3,624 or $3,660 =$
Intrust Super Cup @ $3,932 or $3,980 =$
FOGS Colts @ $3,624 or $3,660 =$
Total Part C $
Loss of Income Top-Up Cover – PART D
PLEASE NOTE: A $300 per week loss of income weekly benefit is now automatically included for all
senior teams / players (teams participating in U19 or above competitions). Should a team or individual
player require a higher limit, there are top up options available by entering into the below table, otherwise
you can direct your teams / players to Gallagher on 1800 SPORT 0 (1800 776 780) directly.
Team / Individual Player Loss of Income Top-Up
Weekly Benefit Premium
(Refer page 5-6 of the handbook)
Team grade /
$
Player Name:
Team grade /
$
Player Name:
Team grade /
$
Player Name:
Total Part D $
Total cost of insurance
Total Premium Payable (Part A, B, C, D): $
QRL 2018 Insurance Declaration | Page 7Queensland Rugby League
2018 Insurance Declaration
Duty of Disclosure
Before you enter into a contract of general insurance with an Insurer, you have a duty at law to disclose to the Insurer
anything that you could be reasonably expected to know is relevant to the Insurer’s decision whether to accept the risk of
the insurance and, if so, on what terms.
You have the same duty to disclose those matters to the Insurer before you renew, extend, vary or reinstate a contract of
general insurance.
Your duty however does not require disclosure of matter:
• that diminishes the risk to be undertaken by the insurer;
• that is of common knowledge;
• that your insurer knows or, in the ordinary course of business ought to know;
• as to which compliance with your duty is waived by the insurer.
If you fail to comply with your duty of disclosure, the Insurer may be entitled to reduce its liability under the contract in
respect of a claim or may cancel the contract.
If your non-disclosure is fraudulent, the Insurer may also have the option of avoiding the contract from its beginning.
Declaration & Acknowledgments
I/We declare and acknowledge that I/We:
• have not suppressed, misrepresented or misstated any material information within my knowledge likely to affect the
Insurers decision as to my eligibility for insurance and the answers given in the Proposal and the completed quote
questionnaire are in every respect true and correct.
• have received, read and fully understand the details contained in the 2018 QRL Community Insurance Program
Handbook. Furthermore, I acknowledge the property insurance program is an optional policy and that cover will only
commence upon written acceptance of a formal quotation provided by Gallagher.
• acknowledge that the public liability insurance component of the insurance program is intended to provide cover for
“normal” activities of Rugby League. Activities outside of Rugby League including but not limited to fundraising and
social activities may not be covered under this policy and should be referred to Gallagher for clarification.
• subject to the Insurance (Agents and Brokers) Act, if this Proposal is accepted by the Insurer, the Proposal, the
Policy and Schedule issued shall constitute the entire agreement between you and us, and shall supersede any prior
representations or warranties.
Signature of President, Treasurer or Secretary
Name of President, Treasurer or Secretary
Date / /
Gallagher. NRL Whole of Game ProgramImportant Checklist
General
Has the Duty of Disclosure been signed and dated? Yes No
Have you attached copies of any contractual Agreements signed by the Club /
Yes No
Local League?
If you are claiming Stamp Duty Exempt status have you attached a copy of your
Yes No
certificate from the Office of State Revenue?
Payment Options (tick)
1. Cheque for $ made payable to “Arthur J. Gallagher” is attached
2. Direct Debit Option – if you wish to pay by an on-line direct debit transfer, please forward your completed
declaration. On receipt we will email your invoice back to you, with your own clubs dedicated Direct Debit
details for easy transfer
3. Premium Funding – if you wish to Fund please contact Gallagher on 1800 SPORT 0 to obtain a Funding quote,
as per below process.
NOTE: If you would like a funding quotation for monthly instalments please follow these steps:
1. Phone 1800 SPORT 0 (1800 776 780) and advise that you are a “QRL Club requesting a Premium Funding Quotation”.
2. Have your total team numbers ready.
3. A quote & contract will then be emailed to you
4. If you accept the funding contract, simply complete, sign and return directly to Gallagher, together with your
completed 2018 QRL Insurance Program Declaration.
REMINDER: Completed documents must be forwarded directly to Gallagher, by no later than the 28 February 2018.
Please return the completed Declaration together with your Payment / Loan
Agreement directly to Gallagher Sport, PO Box 302, BEENLEIGH QLD 4207
QRL 2018 Insurance Declaration | Page 9Queensland Rugby League
2018 Insurance Declaration
Contacts – Gallagher
Branch Brisbane sport and fitness team
25 Main Street, BEENLEIGH, QLD, 4207
Postal Address: PO Box 302
BEENLEIGH QLD 4207
Phone: 1800 SPORT 0 (1800 776 780)
Fax: 07 3367 5100
Team Leader Terry Berryman
Phone: (07) 3367 5010
Mobile: 0438 596 939
E-mail: terry.berryman@ajg.com.au
Internal Account Executive Julian Jemmott
Phone: (07) 3367 5146
E-mail: julian.jemmott@ajg.com.au
Assistant Account Executive Bryce Stevens
Phone: (07) 3367 5072
E-mail: bryce.stevens@ajg.com.au
Gallagher. NRL Whole of Game ProgramQRL 2018 Insurance Declaration | Page 11
Arthur J. Gallagher Insurance Brokers. AFSL 238312. To the extent that any material in this brochure may be considered advice, it may only be considered general advice as it does not take into account your personal objectives, needs or financial situation. Arthur J. Gallagher urges you to read the relevant policy wording and consider whether any products are appropriate for your situation before making a decision to acquire insurance. 1800 SPORT 0 (1800 776 780)
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