Request for Change of Authorised Agent

Request for Change of Authorised Agent

Need Help? Call (03) 9234 3285

By completing this form, you are authorising the management of all premium/debt collection and claims relating to the following employer to Allianz Australia Workers' Compensation (Victoria) Limited ACN 059 835 791. If you are transferring more than one business, please complete a separate form for each.

indicates mandatory information.

WorkCover employer number (if known):
Employer legal name:
Street address:
Name of person completing this form:
Contact number of person completing this form:
Position in business/company:
Name of your accountant or broker:
Your accountant or broker's contact number:
Which Allianz office would you like managing your Workers’ Compensation business:

Need help?

If you need help completing this form, or would like further information about transferring your policy, please telephone Allianz on (03) 9234 3285 or 1800 240 335 (Victoria only).
Transfers take effect on the first of each month. To ensure your policy is transferred at the earliest opportunity, your request must be lodged with Allianz before the 20th of the month.

Allianz Australia Workers’ Compensation (Victoria) Limited ACN 059 853 791

GPO Box 80, Melbourne VIC 3001. Telephone (03) 9234 3285 Email