Are you a current member of I.E.T.A.? ADDRESS Yes No If yes, please add your Client Code below: TELEPHONE

Transcription

1 APPLICATION FOR MEMBERSHIP & PUBLIC LIABILITY INSURANCE FOR MEMBERS OF THE IRISH EXERCISE TEACHERS ASSOCIATION (REPRESENTING FITNESS & DANCE INSTRUCTORS) Please type/write in BLOCK CAPITALS NAME Are you a current member of I.E.T.A.? ADDRESS Yes No If yes, please add your Client Code below: TELEPHONE (If you are not a current member of the Irish Exercise Teacher s Association, your qualification must be approved before insurance cover can be arranged. When submitting your application, please attach a copy of your examination certificate for assessment.) DETAILS OF QUALIFICATIONS Current members should enclose a copy of their current examination certificate of qualification. a b c TYPE YEAR QUALIFIED YEAR RE-CERTIFIED Has any claim been made against you in the past 5 years? Yes No Are you aware of any injury to, or death, disease or illness to any clients or other circumstances which may give rise to a claim against you? Yes No If the answer to either of the above questions is yes, please give full details on a separate page DETAILS OF TYPE OF ACTIVITY ACTIVITIES Full Time Group Exercise Dance Part Time Personal Training Children s Fitness Water Fitness Other? Older Adult Please specify PUBLIC LIABILITY Please indicate the limit of indemnity you require (please see premium amounts on page 3) 2,600,000 6,500,000 EMPLOYERS LIABILITY Please indicate if you require Employers Liability Premiums are in addition to your category premium Yes No Payment Details 1 Employee /3 Employees /8 Employees

2 CATEGORY 1 WHERE DO YOU OPERATE FROM? PAYMENT DETAILS Community Centre/School Public Liability Premium Leisure/Sports Centre IETA Membership Client s home Total Due Hospital/Clinic Other? Please specify Premium inclusive of 5% govt. levy CATEGORY 2 WHERE DO YOU OPERATE FROM? PAYMENT DETAILS A permanent business premises Public Liability Premium Rent IETA Membership Lease Total Due Hire Own Premium inclusive of 5% govt. levy At Own House DECLARATION I declare that to the best of my knowledge and belief the above statements are true and complete and will form part of the contract between myself and the insurers. I attach cheque for MADE PAYABLE TO O BRIEN FINLAY INSURANCE ASSOCIATES LTD, in respect of the premium and I.E.T.A. membership subscription. Membership applies from the date of acceptance by I.E.T.A. The Public Liability/Employers Liability Insurance does not operate until the application form and premium is accepted by and paid to O Brien Finlay Insurance Associates Ltd who will then issue a Certificate of Insurance. NOTE Membership applies from the date of acceptance by I.E.T.A. The Public Liability insurance does not Signature operate until the application form and premium is accepted by and paid Date to O Brien Finlay Insurance Associates Ltd who will then issue a Certificate of Insurance. NOTE Membership applies from the date of acceptance by I.E.T.A. The Public Liability insurance does not

3 SYNOPSIS OF LIABILITY COVER AVAILIBILITY All current members of the Irish Exercise Teachers Association ( I.E.T.A) practising in Ireland & who comply with the I.E.T.A Code of Ethics COVER- SECTION 1 - EMPLOYERS LIABILITY (This insurance is operative only if shown as such on the certificate) The Company will provide indemnity to any Person Entitled to Indemnity against legal liability of any damages in respect of Injury of any Person Employed caused during any Period of Insurance in the Republic of Ireland arising out of and in the course of employment by the Insured in the Business INDEMNITY LIMIT 13,000,000 Premium as follows: 1 Employee including Government Levy 2/3 Employees including Government Levy 4/8 Employees including Government Levy COVER- SECTION 2 - PUBLIC LIABILITY The Company will provide indemnity to any Person Entitled to Indemnity up to the Limit of Indemnity against legal liability for damages in respect of accidental Injury of any person accidental loss of or damage to Property nuisance trespass to land or trespass to goods or interference with any easement right of air light water or way other than legal liability for damages which result from a deliberate act or omission of the Insured or which is a natural consequence of the ordinary conduct of the Business and which could reasonably have been expected by the Insured having regard to the nature and circumstances of such act or omission breach of professional duty consequent upon any neglect error or omission in providing advice or treatment happening during any Period of Insurance in connection with the Business INDEMNITY LIMIT As shown on the certificate of Insurance Premium as follows Limit of Indemnity 2,600,000 Category including Government Levy Category including Government Levy Limit of Indemnity 6,500,000 Category including Government Levy Category including Government Levy The above premiums exclude IETA membership fee BUSINESS Fitness/Exercise & Dance Instruction. TERRITORIAL LIMITS The Republic of Ireland PERIOD OF COVER As shown on the Certificate of Insurance. SPECIAL CONDITIONS Accurate descriptive records of all professional services are to be maintained. Immediate notice should be given of any claim or situation/occurrence that could give rise to a claim.

4 POLICY The above is a brief synopsis of policy cover provided under Policy No. SA underwritten by RSA Insurance Ireland Ltd. Full details are set out in the policy document which is available on request. This application form can be used to apply for membership and insurance for new or existing members. For your convenience, IETA in association with O Brien Finlay Insurance Associates Ltd, have made it possible to obtain membership and Liability insurance in one easy payment. IETA AIMS To provide support and a communication network to members through workshops, seminars and articles. To promote up-to-date information on issues, trends and developments in the exercise and fitness areas. To promote better standards of exercise and dance instruction and teacher training courses. To increase public awareness of the benefits of exercise and healthier lifestyle. To establish a working relationship with other professional organisations both in Ireland and abroad. LIST OF RECOGNISED BODIES/ORGANISATIONS National College in Exercise and Health Studies ( N.C.E.H.S.) National College in Exercise and Fitness ( N.C.E.F.) International Dance Teachers Association Reebok Institute ( I.D.T.A.) Irish Academy of Body Sculpting ( I.A.B.S.) National Association of Teachers in Dance ( N.A.T.D.) Royal Academy of Dance (R.A.D.) Stott Pilates Bodyfirm, Dublin Bodyfirm (YMCA) SCSM YMCA UK Royal Society of Arts (RSA) Aerobic & Fitness Association of America (AFAA) Institute of Technology Tralee Profi Fitness School National Training Centre Cork Institute of Technology International Therapy Examination Council ( I.T.E.C.) Imperial Society of Teachers of Dancing (I.S.T.D) American Council on Exercise ( A.C.E.) American Academy of Body Sculpting Michael Kind Pilates UK Physical Mind Institute New York National Exercise and Sports Trainers Association NASM Personal Training OCR UK Gyrontonic full qualification Zumba Fitness Portobello Institute Waterford Institute of Technology Institute of Technology Sligo HOW TO ARRANGE COVER I.E.T.A Membership and Insurance can now be arranged in one easy transaction! Just fully complete the application form overleaf and return it to us with your cheque. If you are applying for membership of I.E.T.A for the first time, your qualification must be approved before insurance cover can be arranged. If this is the case, please complete the application form overleaf and forward a copy of your examination certificate for assessment. Cost of I.E.T.A membership fee 25.00

5 INSURANCE QUERIES please contact: MEMBERSHIP QUERIES please contact: Trevor/Emma/Ewa/Alex or Michelle Maeve Clegg O Brien Finlay Insurance Associates Limited Bridge House Baggot Street Bridge Dublin 4 T: T: F: E: [email protected] E: [email protected]

6 FOR PAYMENTS BY LASER / VISA / MASTERCARD- PLEASE COMPLETE: I/We authorise you to debit my Laser / Visa / MasterCard Account with the amount of My Laser / Visa / MasterCard Number is:- / / / / Date Card Expires / Security Code {on back of card-credit Cards only} Name (as on your card) BLOCK CAPITAL LETTERS ONLY Cardholders Address Signature Date