EFT Payment Details

Are you a:

Provider Employer Injured Worker

What type of request is this ?

New Update

Policy Name

Policy Number

Contact Name

Contact Number

Email Address

Postal Address 1

Postal Address 2

City

State

Postcode

Full Account Name

Bank Name

BSB Number

Account Number

Please complete the above details and ensure you sign this form.

I confirm that I authorise Allianz to CREDIT monies relating to the reimbursement of Workers' Compensation invoices to the account mentioned above.

Signature

Date