EFT Payment Form for external motor repairers

Please note all fields are mandatory

What type of request is this?:

ABN:
Lookup ABN
X
Company name:
Trading name:
Accounts Phone Number:
(incl area code)
X

Example: 0392414141 (Landline); 0412345678 (Mobile)
Address:
Suburb:
State:
Postcode:
Accounts email address:
Note: A permanent generic company email address, such as accounts@bigcompany.com.au should be supplied, rather than a personal company email address, e.g. john@bigcompany.com.au
Contact Person:
Bank Name:
Branch Location:
Bank Account Name:
Account Number:

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Privacy Notice: We collect your personal information directly from you where reasonably practicable or if not, from other sources such as a member of your staff who has your permission to provide the required information on your behalf. The information requested on this form is being collected by Allianz Australia Insurance Limited in order that payments for goods and/or services supplied by the company named in this form may be made to the bank account nominated on this form. If you do not provide this information, we may not be able to make payments by electronic funds transfer to your account. This information is provided on a voluntary basis and you may contact Allianz on 1800 000 284 (EST 8am - 6pm Monday to Friday) or via email to customerservice@allianz.com.au for access to your information or to make a privacy complaint at any time. Where you provide us with information about another person or entity for the above purposes, you must tell us if you have not got their consent to do this.