NSW Request for Workers' Compensation Policy

Have you notified your current insurer that you are insuring with Allianz?

To complete cover answer the following mandatory questions marked with a *.

Policy Details
Date: *
Inception Date: *
Expiry Date: *
Employer's Details
ACN:
ABN:
Are you registered for the GST? *
What is the Input Tax Credit entitlement?	%
Trading Name: (if applicable)
Legal Entity: *	(If a sole trader – please include middle name e.g. John Steven Smith)
Legal Entity Type: *
Employer's Postal Address (Within Australia Only)
Street Number or PO Box: *
Suburb: *
Postcode: *
Employer's Risk Address
Must be the primary worksite for your employees and not a post office box.
Street Number & Name: *
Suburb *
Postcode: *
State: *
Employer's Contact Details
Contact Name: *
Phone: *
Email Address:
Employer's Business Information
What is the main activity of the business? (full details required) *
What industry is the business involved in? *
Workcover Industry Classification (WIC):	(You can use our easy on-line search database to find the correct WIC code.)
Estimated number of employees: *
Estimated wages / shifts: *	$
Do you have any apprentices engaged in an approved training contract with the NSW Department of Education and Training? * (Note: These details must also be included in your total estimates.)	Yes No

Have you purchased an existing business? *

Intermediary Details
Intermediary Name:
Intermediary Number (if applicable):
Intermediary Address:
Intermediary Phone No.:
Intermediary Email Address:
Do you require Allianz to post an application form to the insured?

Policy Confirmation
Please note: Upon submission of this form, a Workers’ Compensation policy will be in effect and the applicable premium charged. Please confirm that you wish to proceed by checking the following box:

Estimated number of apprentices: *
Estimated apprentices wages: *	$