Make a Claim
Broker Application Form
Your Details
Full Name
*
Trading Name
*
ABN
*
AFSL Number
*
Business Address
Street
*
Suburb
*
State
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Postcode
*
Contact Information
Telephone Number
*
Fax Number
*
Mobile Number
*
Email Address
*
Active Directors or Managers
*
Name
Qualifications
Insurance Experience
Registration as Broker
Registration Number
*
Date of Application
Date Format: MM slash DD slash YYYY
Are you a member of NIBA?
*
Yes
No
Do you have a Broker Administration Agreement in place with Allianz Australia Insurance Limited?
*
Yes
No
If you have a Broker Administration Agreement in place with Allianz Australia Insurance Limited, please provide Primacy with your Account Number and Account Manager details via email to primacy@pum.com.au. You do not need to complete this form if you have a Broker Administration Agreement in place with Allianz.
Professional Indemnity Insurance
Insurance
*
Registration Number
*
Limit
*
Deductible
*
Please provide a copy of your current certificate of insurance
*
Accepted file types: jpg, png, tiff, pdf, doc, docx.
Fidelity Guarantee Insurance
Insurance
*
Registration Number
*
Limit
*
Deductible
*
Please provide a copy of your current certificate of insurance
*
Accepted file types: jpg, png, tiff, pdf, doc, docx.
QUESTIONNAIRE
Portfolio
A. What is the anticipated annual premium income generated by your brokerage?
Commercial Premium
*
Domestic Premium
*
Crop Premium
*
Total Premium Income
*
B. Please supply details of other Insurers with whom you transact business.
*
Company Name
Premium
Percentage %
C. Has any general insurance company that you do business with restricted account credit terms?
*
Yes
No
Your References
D. Commercial References
Bank
*
Branch
*
Manager
*
Phone
*
Accountant
*
Address
*
Contact
*
Phone
*
E. Insurance References
Name
*
Branch
*
Manager
*
Phone
*
Name
*
Branch
*
Manager
*
Phone
*
F. Have any of the directors or partners of the applicant company been involved with insolvency or bankruptcies?
*
Yes
No
G. Have any of the directors or partners of the applicant company been convicted of a criminal offence?
*
Yes
No
H. Please confirm by answering yes below that you consent to Primacy employing all necessary credit or reference checks to research the background and viability of the applicant company.
*
Yes
No
I. Please provide your latest audited financial report. By uploading this document you consent to Primacy's use for the purpose of assessing your application.
*
Accepted file types: jpg, png, tiff, pdf, doc, docx.
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