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: 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 AEST) 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.