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Teacher Insurance :: KlaptonOnline
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Teacher Insurance Application Form
Note: * Indicates required field.

Applicant Information

Requested Third Party and Professional Indemnity Insurance Limits and Deductible

Limit Per Claim* :
Deductible Per Claimant* :

Applicant Information

Insured Information

Use the Applicant's name and address

Insured Business Name

Business and/or corporate name to be included in the Name of Insured.

The policy will show the insured's name, which will include the name of the owner (applicant), the corporate name and trading name. This is in order to provide coverage for your business, as well as yourself.

Professional Information

Choose the group where your practice is listed*. If any of your practices appears in more than one group, choose the higher group (A is lower risk, and C is the highest risk)

A B C
  • ABA Tutor (Applied Behaviour Analysis)
  • AED Instructors
  • Agricultural Teachers
  • Alexander Technique Teacher
  • Arts and Crafts Instructors
  • Babywearing Instructor
  • Beauty and Hairdressing Instruction
  • Belly Dance Instructor
  • Car Mechanic Teacher and Instructor
  • Children and Teeagers Dance Instruction
  • College/University Instructors
  • Computer Instructor
  • Cooking Classes
  • Counseling Teacher
  • CPR Instructors
  • Dance Instructors
  • Day Care/Creche
  • Drama/Theatre Teachers
  • Early Intervention Services
  • Educational Consultant
  • Educational Diagnosticians
  • Educational Events Organizers/Directors
  • ESL Teachers
  • First Aid Trainers
  • Geography Teachers
  • Gymnastics Instructor
  • Home Economics Teachers
  • K-12 Classroom Teachers
  • Language Instructors
  • Librarians
  • Marriage Teacher/EducatorMeditation Teacher/Instructor
  • Montessori Teachers
  • Music - Home Tuition
  • Music Teachers
  • Nature and Wildlife Instructors
  • Peripetitic Language Teacher
  • Phlebotomy Training and Instruction
  • Physical Education Teachers
  • Practice Educator/Observer
  • Primary School Teachers
  • Private Nanny
  • Private Tutors
  • Qigong Teachers/Instructors
  • Reiki Teacher
  • School Principals
  • Secondary School Teacher
  • Sign Language Instructors
  • Social Studies Teachers
  • Special Education Teachers
  • Student Teacher
  • Substitute Teachers
  • Technical Drawing Teachers
  • Tutor/Home Tutor
  • Water Safety Education
  • Wheelchair Dancing Instructor
  • Yoga Meditation Teachers and Lecturers
  • Yoga Teachers/Instructors
  • Aquanatal Instructors
  • Aquatic Safety Instructors
  • Childbirth Educators
  • Children and Teenagers Fitness Program Instruction
  • Infant Massage Instructor
  • Martial Arts Educators
  • Wood Shop Teachers
  • Lifeguard Educators
  • Swimming Instructors

*If your trade does not appear in the list, please refer to our team for a personal quote.

Coverage Extensions

Occurrence Retroactive Date Coverage for the following previous period:

Claim Made Date Coverage for the following future period:

Coverage and include additional professionals/practitioners to this cover:

Coverage and include additional administrative employees to this cover:

Acknowledgement and Declarations

I hereby declare that within the last 5 years:

I had not been revoked, suspended, refused, cancelled or voluntarily surrendered any of the following:

  1. State license, certification or registration
  2. Malpractice insurance
  3. Public liability insurance

No claim or suit for alleged malpractice or public liability has been brought against me and I am not aware of any incident that might reasonably lead to such claim or suit. I have never been convicted (as an adult) of a felony and there isn’t any such case pending. No complaints or charges were brought against me by any licensing board or professional ethics body.

I hereby confirm that I have read and agree with the above statement.

I, the undersigned declare that all answers in this application form are complete and accurate. I understand completely that the answers provided are the basis for the provision of Insurance Cover. Furthermore, I declare that I do not have any supplementary information, in respect of this application, which could influence the outcome of your decision regarding my application request. My signature warrants that my application is submitted in all good faith.

I hereby confirm that I have read and agree with the above statement and it applies both to me and to any additional professional/practitioner and administrative employee included in this application.

Premium Payment Information: I hereby confirm that I understand that after completing and submitting this application form, I must pay the required premium before any cover will become effective.

Submitted Date: 16 Sep 2019