WorkCover employer number (if known):
Employer legal name:
Street address:
Postcode:
Name of person completing this form:
Contact number of person completing this form:
Contact email of person completing this form:
Position in business/company:
Name of your accountant or broker:
Your accountant or broker's contact number:
Your accountant or broker's contact email:
Which Allianz office would you like managing your Workers’ Compensation business:
-- Please Select --
Melbourne - Level 26, 555 Collins St, Melbourne VIC 3000
Geelong - 117 Myers St, Geelong, VIC 3220
Moe - 46 Haigh St, Moe, VIC 3825
Your Workers' compensation Premium (if known):
