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Amateur Football Team Insurance Online Application

Please only complete this online proposal form if you wish to proceed with purchasing this insurance through us. Please note that applications can only be processed Monday to Friday between 9am and 5pm and cover cannot be backdated. Cover will only be held once confirmed by David J Miller Insurance Brokers. Before completing this application online please ensure that you have read our football insurance brochure detailing all the relevant premiums and options available. This can be seen by clicking here Football Insurance Premiums & Benefits Brochure
Contact Name (*)
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Full Name of Club (*)
Please type your full name.
Name of Secretary (*)
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Address of Contact (*)
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Town
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Postcode (*)
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Contact Number (*)
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E-mail (*)
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County Association affiliated to (*)
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Affiliated League Name (*)
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Cover Start Date (Cannot be backdated) (*)
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Please advise us the level of cover you require as detailed within the policy information and premiums & benefits brochure which can be seen by clicking here Football Insurance Premiums & Benefits Brochure. Please ensure that you have fully read and understand the different options available and that the cover you opt for meets with your requirements prior to completing this application.
Do you require Adult team cover? (*)
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Number of Adult 11 a side teams? (*)
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Please select the Adult level (scale) of cover required for your Adult 11 a side team(s)
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Number of Adult 5/7 a side teams? (*)
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Please select the Adult level (scale) of cover required for your Adult 5/7 a side team(s)
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Do you require Adult additional benefits? (*)
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Do you require Youth team cover (*)
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Number of Youth 11 a side teams? (*)
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Please select the Youth level (scale) of cover required for your Youth 11 a side team(s)
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Do you require Youth 11 a side additional benefits? (*)
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Enter the number of Youth 11 a side teams with 16 - 18 year old players that require youth additional benefits (*)
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Number of Youth Mini teams? (*)
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Please select the Youth level (scale) of cover required for your Youth Mini team(s)
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DECLARATION & MATERIAL FACTS
Before purchasing your football insurance online please ensure that you have read and understood the Policy Summary of Cover, Key Facts, Policy Wording and our terms of business which can be viewed by clicking on the links here. Summary of Cover, Key Facts, Policy Wording, Terms of Business
I have read and agree with the Statement of Fact which are seen on page 6 of the Summary of Cover (*)
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I have read and agree with the Terms of Business Agreement (*)
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I have read and understand the Summary of Cover & Key Facts (*)
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I am aware that this Policy is subject to the Policy Wording which I have read and understand (*)
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Please advise how you wish to pay. (Please note there will be a 1.25% surcharge applied for all credit card payments).
Payment Method (*)
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I / we understand that by completing this proposal form we enter into an agreement to purchase the requested insurance as set out within this proposal and to settle any payments due upon demand. (*)
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Date Proposal Completed (*)
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How did you hear about us? (*)
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