NSW Intermediary Online Policy Request Form

To request a Policy, please complete the following mandatory questions marked *. You will receive a response in 24 hours (excluding weekends and public holidays). Remember Workers Compensation is compulsory for employers. If you proceed with a policy request a Premium charge will apply.

*QBE Branch: 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:   *Expiry Date:
*Full Name of Employer:
*Contact Name:
*Contact Number:
Fax Number:
Email Address:
 Employer's Physical Address:
*Street:
*Suburb:
*State:     *Post Code:
 Employer's Postal Address:
Tick here if your physical address is the same as your postal address
*Street:
*Suburb:
*State:     *Post Code:
Employer's Business Activity
*Full Description of Business:
eg. Aluminium windows installation
WICS Code Recommended:
Client Business ABN:   ACN:
*No of Employees:
*Estimate of Wages:
(Exclusive Of Superannuation)
*Superannuation:  Don't Know
Termination Payments:  Don't Know
Total:
*Is the employer a member of a group? Yes  No  Don't know 
If Yes, please provide Group Number
Name of previous Insurer:
Policy Number:
*Is the business a new venture? Yes   No 
*Has the client bought an existing business? Yes   No 
      If Yes, please provide the previous owner and contact details if known.
Name of previous owner:
Phone Number:
Comments:
Please ensure that the current insurer has been advised that the existing policy is to be lapsed before 4pm on due date of policy.