INSURANCE INFORMATION STATEMENT-2006

1. Name of School/Academy/Club……………………………………………………………………

2. AKWF Membership Number: …………………………………………………………………….

3. Number of Accredited Instructors at your School/Academy/Club:……………………..

4. Approximate number of students training at your School/Academy/Club:……….….

5. Approximate number of students that attend each class;………………………………..

6. Are you currently Insured or have you been insured over the last three years; YES [ ] NO [ ]

7. If yes what is the name of your current or past insurer:…………………………………..

8. What is the premium paid by you for your most recent insurance policy:…………….

9. Have you at anytime been declined insurance:………………………………………………

10. Have you, over the last ten years, made any claim against your club/school/academy

insurance:…………………………………………………………………………………………………

11. Name of the person providing this information:…………………………………………….

12. Contact Phone number;………………………………………………………………………….

13: Contact Email:……………………………………………………………………………………..

14: Contact Address:………………………………………………………………………………….

15. Please list what style or styles of Kung Fu you teach at your School/Academy:

……………………………………………………………………………………………………………….]

………………………………………………………………………………………………………………...

16. Attachments: If you have answered yes to Q. 6 you must attach a copy of your most recent insurance and proof of amount of premium paid.

I the undersigned provide this information in the knowledge that if it subsequently proves false or misleading any insurance cover issued as a consequence of this information may be cancelled.

Signed:……………………………………………………… Dated:………………………………