Workers Compensation Quote – Medical and General Risk Solutions

Name of Entity/Employer

ABN*

Main business address*

State Postcode

Describe your practice

e.g. GP clinic, Radiology practice, Obstetric practice

Estimate director wages for the next 12 months

Estimate employee wages for the next 12 months

Do you currently have workers compensation cover?

Insurer name

Due date

Total annual premium

What date do you need the insurance policy to commence?

Provide any other information you feel is relevant

Your preferred name

Mobile number*

Email address*

Preferred contact method*

Preferred time to contact

: HH

MM