2022 Rotary Clubs and Club Trusts Insurance Programme Information

Your Club, Club Trust or other Trust Name *

Country *

Type of organisation *

Number of members, shareholders or beneficiary classes as at 1 July 2021 *

Approximate annual revenue to 30 June 2021 *

Asset insurance *

Insurance History - claims *

No Claims madeClaim made
Claim based on negligence or other failure to carry out duties
Claim for loss of property, monies or investment
Claim for cyber loss
Claim by employee
Claim by member, shareholder or beneficiary
Claim by minor or their guardian relating to any duty of care or protection
Claim for damage to others property including motor vehicles
Claim relating to any organised event or project run tby the organisation
If other, please specify:

Is there situation that you think might give rise to a claim? *

If yes or NOT sure, please specify:

The full name of the person completing *

Title or role of person completing *

Date completed *

Your email address please *

The mobile number for the person completing and any other way you can be contacted *

Do you agree that the answers provided are based on the Rotary International Privacy Policy attached to the survey *

On insurance information you understand that the information must be true and correct *

If other, please specify:

You have not suppressed, misrepresented or misstated any relevant fact. *

If other, please specify: