New Policy ‐ Workers Compensation Portal

New Policy

Please note that the form needs to be completed once started as we cannot save your information in draft.
It is extremely important that this form is completed with as much detail as possible.

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Insurance proposal details

What is primary business activity? *

Period Start *

Period End *

Legal Name *

Entity Type *

Trading Name

Business Commencement Date *

ABN *

ACN

Primary Physical Address *

If applicable

Primary Postal Address *

Same as Physical address

Trading Name	Contact Name	Contact Number	Email	Physical Address	Purchase Date

Contact Person

First Name *

Surname *

Position *

Email *

Phone

Mobile

Do you have a Broker for Workers compensation? *

Yes No

Are you a member of ClubsNSW/Australian hotels Association (AHA)? *

Yes

Are you registered for GST? *

Yes

Do you have an input taxt credit entitlement (ITC) of 100%? *

Yes

Entitlement % *

Have you purchased/taken over company in last 12 months? *

Yes No

Date purchased/taken over

Has there been a Workers compensation policy in last 2 years for this business?

Related Corporations

Is your organisation related to another company, subsidiary? *

Yes No

Grouping of Related Employers

Are you a member of a Group that pays combined wages in excess of $750,000? *

Yes No

Business Activity	Main Operations	Total

Is there anything else you would like us to know? *

Yes No

Please upload any other information of relevance

Accept file types .pdf, .doc, .docx, .jpg, .jpeg, .png, .bmp, .tif, .tiff, .msg Maximum allowed file(s) size is 20 MB

Would you like us to contact you? *

Yes No

Would you like to set up direct debit now? *

Yes No

Declaration:

By replying to this email, you are declaring that you are the Employer or an authorised representative and:

The information provided, and any attachments is true, correct, and complete
No information has been suppressed or omitted
That all information supplied is made in accordance with the records required to be kept under the Workers Compensation Act 1987
You acknowledge that the terms and conditions of the policy are as prescribed by Schedule 3 of the Workers Compensation Regulation 2010
You consent to the information provided in this form, and any further information provided, being used for the purpose of evaluating and administering the employer's workers compensation policy and any related purpose
You are authorised by the employer to reply to this email on behalf of the employer

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New Policy

Insurance proposal details

Additional Locations

Contact Person

Insurance for last year and year before last

Related Corporations

Grouping of Related Employers

Business Operations

Declaration:

Privacy Statement