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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:
BSB:
Check BSB Number
Account Number:

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Privacy Notice: The information requested on this form is being collected by Allianz Australia Insurance Limited so that payments for goods or services supplied by the company named in this form may be made to the bank account nominated on this form. We collect your personal information directly from you where reasonably practicable or if not, from other sources who have your permission to provide the required information on your behalf, such as a member of staff. Providing this information is voluntary, however if you do not provide this information, we may not be able to make payments by electronic funds transfer to your account. Where you provide us with information about another person or entity for the above purposes, you must tell us if you don’t have their consent to do this by calling us on 1800 000 284 (Monday to Friday, 8am - 6pm AEDT) or emailing our Customer Service team.

Our Privacy Policy contains details about how you can request access to your personal information, make a complaint about a breach of the privacy principles contained in the Privacy Act 1988 (Cth) and how we deal with complaints.

Any advice here does not take into account your individual objectives, financial situation or needs. Terms, conditions, limits and exclusions apply. Before making a decision about this insurance, please consider the relevant Product Disclosure Statement (PDS)/Policy Wording and Supplementary PDS (if applicable). Where applicable, the PDS/Policy Wording, Supplementary PDS and Target Market Determination (TMD) for this insurance are available on this website.

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Allianz acknowledges Aboriginal and Torres Strait Islander peoples as the Traditional Custodians of the lands on which we live and work across Australia. We pay our respect to First Nations Elders past and present.

Allianz Australia Insurance Limited ABN 15 000 122 850 AFS Licence No. 234708 is the general insurer except in respect of life insurance, in which case Allianz Australia Life Insurance Limited ABN 27 076 033 782 AFS Licence No. 296559 is the insurer.

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