English Karate Federation Instructor Insurance Proposal Form

Please complete this form including all mandatory fields. Proposal form will be submitted upon successful payment where your proposal will be processed. Please contact Registration for queries.

Fun4Sure & LRO Insurance

It is essential you provide us with ALL MATERIAL FACTS. Failure to disclose all material facts may invalidate your insurance or may result in the insurance not operating fully.

Name of Instructor Applicant: Name of Applicant's Registered Association/Club: EKF Licence No: EKF Licence Start Date:

EKF Licence Expiry Date:

Address: Post Code: Contact Telephone No: Contact Email Address:

Karate Dan Grade: Details of Coaching Qualifications: Maximum Number of Classes per Week: Maximum Duration per Class (hrs) Name all Disciplines Coached: Describe Use of Weapons if any: (Use of Any Live Weapons is Excluded) Percentage of Activities - Full Contact:

Do you sell goods to the public: Yes No

If 'Yes' please note cover is limited to:
Products limited to Food & Drink and/or Associated Sports Equipment and/or Accessories sold or supplied

Public Liability Limit of Indemnity Required: Start Date for Insurance:

Claims History

Please provide details of any previous claims made.

Date of Incident:

Reserve/Settlement £: Details of Incident:

Date of Incident:

Reserve/Settlement £: Details of Incident:

Declaration

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. I understand that non-disclosure or misinterpretation of a material fact may entitle insurers to void the insurance. (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.

I confirm I am minimum 18 Years old I confirm I have a Valid and Vetted DBS Certificate I confirm I have a Valid and Current First Aid Qualification or a Qualified First Aider will be present at all times

Signature of Proposer:

Date: Friday, 19 April 2024 (EDT)

Name:

Type your name to sign this document:

Typing name is equivalent to a handwritten signature

Scan this QR code with your phone:

Confirm Name of Proposer:

Fun4Sure & LRO Insurance are trading names of Frita Insurance Services Ltd. 150 Minories London EC3N 1LS
Tel: 0207 347 5160; Fax: 0207 347 5161; email info@lroinsurance.co.uk; Website: www.lroinsurance.co.uk;
Authorised & Regulated by the Financial Services Ltd. (FSA Register No. 311136) Registered in England & Wales No. 02761363