On-line Workers Compensation Insurance


Thank you for considering our on-line workers compensation insurance service.   Because Greater National Group is an insurance broker, not an insurance company, we will process your application with major insurance companies in order to find the right workers compensation insurance for you.

Please fill in the following form as fully as possible, then click 'submit' at the end of the form.
You can use the TAB key to move to the next field. We will respond with your terms as soon as we have researched the market for the right available deals that fit your requirements.


Employer details:
1a. Legal Status Of Employer:
Sole proprietor
Co-operative, welfare or charitable organisation
Partnership
Trustee
Company
Other
Details of Other
1b. Australian Company Number - if applicable (Please include copy of certificate of registration):
1c. Have you registered for GST?
Yes No
If yes, please record the following details
1d. Date of registration with Australian Tax Office:
1e. Input Tax Credit Entitlement: %
1f. If you have not registered for GST do you intend to register?
Yes No
If yes, please ensure you provide your GST details to your Authorised Agent immediately upon receipt of this information from the Australian Tax Office.
Workplace details:
2a. Number of workplaces:
(For how many workplaces are you providing details?)
3a. What is the earliest date that workers commenced operations at or began to be managed from this workplace?:
Business of Employer Carried On And Controlled From The Workplace
(The information you provide will be used to identify your predominant activity, so the most appropriate classification can be used in your premium calculation. Please attach any supporting information regarding your activity.
Please contact your Authorised Agent of choice if you require assistance completing these details))
3b. Provide a list of goods or services you intend to product or provide at the workplace:
3c. How will the goods or services be produced or provided?
3d. What is the one main good or service that you intend to produce or provide at the workplace?
3e. Where you supply or will supply to one business, please name it:
Estimate of Wages and Salaries at Workplace:
Current financial year ending 30 June
4a. Estimate the remuneration (salaries, wages, allowances, directoris fees, contractor payments etc. but excluding apprentices engaged under an approved scheme) expected to be paid for workers at this workplace $ (Whole dollars)
4b. Estimate the superannuation expected to be paid for workers at this workplace $ (Whole dollars)
4c. How many full-time workers are employed at this workplace?
4d. How many part-time workers are employed at this workplace?
4e. How many apprentices are employed at this workplace?
Succession:
5a. Are you registering this workplace as a result of a takeover, purchase, relocation or reorganisation of another workplace or workplaces?
Yes No
If yes, please complete the following details:
WorkCover employer number(s)


Duty of Disclosure:
Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?
Yes No
If so, please provide details:
I/We hereby declare that:
My/Our attention has been drawn to the Important Notices accompanying this form and further I/we have read these notices carefully and acknowledge my/our understanding of their content. The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this form and the inception date of the insurance to which this relates I/we shall give immediate notice thereof. I/We authorise GNG and the Insurer to collect or disclose any personal information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact and the Privacy Policy. I/We also confirm that I/we am/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this form and I/we complete this form on their behalf.
Any other comments, requests or relevant information you need to add:
Contacting you about your quote:
In order to select the most appropriate cover for you, it may be important to discuss quote details in person. Please leave a contact phone number and best time to call to facilitate this.
Your full name:
Company/Business/Name of Applicant to be Insured:
ABN:
Your phone number (please include area code):
Your mobile phone number:
Best time(s) to call:
Please send my quote by (select at least one):
email phone fax mail
Your email address:
Your website address:
Your fax number:
Your postal address:
Country: