UIS | Request for Workers Compensation UIS Quote

Contact Details

Email Address:

Phone Number/Mobile:

Business Details

Business Structure:

Company or Insured Name:

Trading As:

ABN No.:

Registered for GST:

Yes

No

Mailing Address

Address Line 1:

Address Line 2:

Town/Suburb:

Postcode:

State:

Situation at Risk

Business Address

Address Line 1:

Address Line 2:

Town/Suburb:

Postcode:

State:

Business Location

Occupation

Business Activities

How long has the business been operating?

Annual Gross Turnover

Insurance Options

Category		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, dishonesty, arson, theft, fraud or violence against any person or property?

Yes

No

If yes to any of the above questions please provide details or phone us to discuss the matter:

In the last 5 years have you had any claims or losses for the type of risks to be insured?

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

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