Short Term Events Application Form
For groups hiring a Church or Hall facility who need Public Liability cover for their event
Event Name *
(i.e.Wedding of John Smith & Jill Jones, Fred Smiths 50th Birthday, etc)
Your answer
General description of the event *
Your answer
Event Type *
Expected Number of people attending the event *
Your answer
Date of Event *
(This form is for one day events only, but can include set-up and pack-up dayes before and after the event if required)
MM
/
DD
/
YYYY
Are set-up and pack-up days required *
(We can cover the day before and the day after the event if needed)
Has this event been run before? *
Your answer
Will Alcohol be served/allowed? *
Required
Will there be a restriction on the service of alcohol? *
Particularly confirm minors won't have access to alcohol. And that limits will be placed on the amount of alcohol served
Your answer
Will there be any gambling? *
Required
Will First Aid be provided in the event of an incident? (Please advise details) *
Your answer
What Security Management will be provided? (Please advise details) *
Your answer
Is there a formal Risk Management plan for the event? *
(Please email us a copy of this plan to event@gjic.com.au)
Your answer
Will there be Rides, Jumping Castles or similar? (if yes Please advise details) *
Your answer
If Yes to Rides will these be provided by an external provider with their own insurance? *
Your answer
Will there be Fireworks, Bonfires, Horse Riding, Underage Drinking or Nightclub Style activities? *
Your answer
Will a stage be installed? (if yes please provide details) *
(Not including fixed stages already within the building)
Your answer
Contact Name *
Your answer
Contact Phone Number *
Your answer
Contact Email Address *
Your answer
Address where event will be held *
Your answer
Postal Address *
Your answer
Any Additional Information? *
(If none write nil)
Your answer
Declaration & Duty of Disclosure *
I/we declare that I/we have not been refused insurance or had special conditions imposed. I/we declare that all information supplied is true and correct and I have not withheld any information that would be of value in assessing the risk or assessing the acceptance of this proposal for insurance, which is incorporated in and forms part of the policy of insurance. YOUR DUTY OF DISCLOSURE: Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contracts Act 1984, to disclose to the insurer every matter that you know, or could be reasonably expected to know, is relevant to the insurers 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 a 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 its business, ought to know; - as to which compliance with your duty is waived by the insurer. NON DISCLOSURE: 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.
Privacy Consent *
I/we agree to allow our personal information to be collected, used and disclosed to Insurers or any related corporation and/or related individual for the primary purposes of evaluating, effecting, managing and administering this or any other insurance cover or financial service or product provided to you. Personal information about you, collected for the above primary purpose may also be disclosed to insurers &/or their service providers, claims consultants and the like. Personal information about you may also be collected, used and disclosed by us for the secondary purpose of informing you of other products and services offered by us &/or related corporations. You may however, at any time, withdraw your consent to the use of information about you for the secondary purposes by advising us at any time. If you do not provide the requested personal information, we may not be able to evaluate, effect, manage or administer your insurance cover and you may breach your Duty of Disclosure.
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This form was created inside of GJ Insurance Consulting Pty Ltd.