JCI | Request for Workers Compensation 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 operated from

Business Address

Is the business address the same as mailing address ?

Yes

No

Business Type

How long has the business been operating?

Annual Gross Turnover

Number of Staff Full Time

Part Time

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

Claim History

In the last 5 years have you suffered any losses or otherwise or have any claims made against you?

Yes

No

	Insurer	Claim date	Type of Claim	Amount Paid	At Fault	Finalized	Description