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Please read the below statement to your customer prior to completing the referral form. Do you consent to Allianz contacting you by telephone or email about the insurance products you have selected to provide you with a quote and so that you can apply for cover? If you consent, your information will be shared with Allianz Australia Insurance Limited. You can find more information about their Privacy Policy which can be found on the Allianz website. By ticking this check box, you acknowledge that you have read the above statement to your customer, obtained their consent and that you have read and understood the Referrer Guidelines, as summarised in the Broker Compliance Obligations document.

Referrer Details
Name:*
Referrer Code:*
Mobile:*
Office number:
Email:*
Referrer Group:*	-- Click to Select -- Australian Finance Group Astute Financial Aussie Choice Aggregation Compare & Connect Connective Services Custom Equity Group Coronis eChoice FAST iConnect Lendi Mortgage Choice Mortgage House National Mortgage Broker Outsource Financial PLAN Smartline Specialist Finance Group Vow Financial
Client Details
First Name:*
Surname:*
Contact number:*
	Mobile Work
Preferred contact time:*	-- Click to Select -- 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM Any time during business hours
Email:
Product Details
Preferred product:*	Building Contents Landlord Motor
Loan type:*	New Loan Refinance Customer Initiated Other
Expected settlement date:
Enquiry:
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