Online Insurance Declaration Online REPs Insurance Declaration Form This online insurance declaration is used for an exercise professional wishing to add the REPs insurance to an existing REPs registration, or to update their current insurance declaration. Please note, for those wishing to apply for registration with insurance, please go to this link to REPs Registration First Time Application. Or to re-register with REPs you can log in to the REPs website. This form applies to those who register at a level with insurance included. Note: Contractors to facilities are not normally covered by any facility's workplace insurance. IMPORTANT: YOU MUST COMPLETE SECTIONS A TO F OF THIS INSURANCE FORMName* First Last Date of birth:* Date Format: DD slash MM slash YYYY Email* Enter Email Confirm Email A - List activities you undertake e.g (Personal Training, Aerobics Classes):*Note: These activities must be within your role as an exercise professional, and within the scope of your knowledge, competency and skill.B - Have you had any previous claims in respect to the insurance being applied for?*YesNoPlease provide more details:*C - What was your total income in the last completed financial year? (excl GST) if you have just started business please tick "just started"*Under $50,000Just startedOver $50,000D - Over $50,000. Please write actual amount.*E - Have you ever been subject to disciplinary proceedings for professional misconduct?*YesNoPlease provide more details:*F - Are you aware of any claims, or circumstances which may result in claims against you?*YesNoPlease provide more details:*Insurance Agreement:* I agree to the insurance terms listed below.Insurance Agreement: On behalf of all proposed Insureds I/ We declare and agree that: a) All information provided, in this proposal or attachments, is true and complete in every respect and that no Material Facts remain undisclosed; b) If this risk is accepted, such information will be incorporated into and form the basis of the contract of insurance; c) I/We understand that Chubb requires this information in order to evaluate this proposal and that the Privacy Act 1993 entitles me/us to have access to, and request the correction of, any information retained; d) Chubb is authorised to disclose information to its advisers, reinsurers, other insurers and parties with a financial interest in the subject matter of this proposal; e) Chubb is authorised to check details against the Insurance Claims Register and to place information on the Insurance Claims Register which other insurers can access; f) Chubb is authorised to obtain from other parties any information which may be relevant to the acceptance of this risk; g) The signing of this proposal does not bind either party to complete the contract and that no cover will be in force until confirmed by Chubb. I/We agree to accept the terms, exceptions and conditions contained in the Professional Indemnity Insurance policy as modified or extended by any endorsements thereon or the policy schedule or on any certificate of insurance issued to me/ us by Chubb in lieu of a policy. h) I/we have read and understood the Rosser Liability “Important Information” relating to Duty of Disclosure, Financial Strength Rating, Privacy Statement and the Personal Information Handling Practice available at www.reps.org.nz/insurance I/We agree that REPs reserves the right to change insurer at any time. This may result in changes to the terms and conditions of the cover, but REPs will ensure the level of cover is comparable. Chubb Insurance NZ LimitedBy submitting the form below this will send a copy of the Insurance Declaration to you and to REPs.