UIS | Request for Workers Compensation Quote

Contacts

Email

Phone number/mobile

Date of birth

Relationship to business

Are additional contacts required?

Yes

No

Business Details

Business structure

ABN

Company or Insured name

Trading as

Registered for GST

Yes

No

Mailing address

Address Line 1:

Address Line 2:

Town/Suburb:

Postcode:

State:

Situation at Risk

Is the business address the same as the mailing address?

Yes

No

Business location

How long has the business been operating?

Annual Gross Turnover

Business Occupation

What industry do you operating in?

Occupation

Do you do any other business/occupation activities?

Does this occupation involve any of the following activities?

Insurance Options

Please provide a listing of staff to be covered under this policy

Category	Number of staff		Estimated wages for 12 months period
Direct Employees			$
Subcontractors			$
Working Directors		Full Names
			$
Total Staff		Total Wages	$

Insurance History

In the last 5 years have you

i. had insurance refused, cancelled, declined, or special terms imposed?

Yes

No

ii. been declared bankrupt, placed in liquidation, receivership, or voluntary administration?

Yes

No

iii. been convicted of or had any fines imposed for any crime involving drugs, dishonestly, arson, theft, fraud, or violence against any person or property, including association with Outlaw Motorcycle Gangs or Organised Crime Gangs?

Yes

No

If yes to any of the above questions, please provide details. Alternatively, call us on (08) 6147 3200.

Claims History

In the last five years has the owner or business suffered any loss or claims made against you that has not already been declared?

Yes

No

Additional Information

Please provide any additional information relevant to your risk, or additional covers you may require

Policy effective date

Policy expiry date

Would you like to pay monthly?

Yes

No

Who is your current insurer?

What is your current premium?

$

What is your current excess?

$

Promo code

	Insurer	Claim date	Amount paid	Finalized	Description
			$