New Policy ‐ Workers Compensation Portal

Employers Mutual Limited trading as Trinity Insurance is authorised to offer Workers Compensation insurance to
employers whose primary business or industrial activity falls within the following description, Roman Catholic Church
and its religious Institutions.

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

Same as Physical address

Primary Postal Address

Contact Person

First Name

Surname

Position

Phone

Mobile

Do you have a Broker for Workers compensation?

Yes No

Brokage Name

Please upload signed letter of appointment

Accept file types .pdf, .doc, .docx, .jpg, .jpeg, .png, .bmp, .tif, .tiff, .msg

Are you registered for GST?

Yes

Exempt

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?

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

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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