Victorian Intermediary Online Cover Note Request

To request a Cover Note, please complete the following mandatory questions marked *. You will receive a response in 48 hours (excluding weekends and public holidays). Please remember Workers Compensation is compulsory for employers.

Date:
 
 Intermediary Details
*Intermediary Name:
*Contact Name:
*Phone Number:   *Fax Number:
Email Address:
NB: You will be emailed a copy of this request if an email address is entered.
Remember my details on this computer.
 Employer Details
*Inception Date:   
NB: Cover cannot be backdated.
*Full Name of Employer:
*Contact Name:
*Contact Number:
 Employer's Postal Address:
*Street:
*Suburb:
*State:     *Post Code:
Comments
Please note that the "Application for Workcover Policy" will be sent directly to your client.