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Please note all fields marked with an * are mandatory
*To:
Attention:
*Referral From:
(Name of Company)
*Suncorp Client Number:
*Fax No:
*Contact Name:
*Phone No:
*Date(dd/mm/yyyy):
Under the Corporations Act 2001
• You are a Referrer of information to the Broker named above
• You are not authorised to provide Personal Advice or General Advice to any client about products which you want the Broker to discuss with them nor
• are you authorised to deal in or arrange an insurance product on behalf of the Broker
I agree as a Referrer, that I have advised my client that the Broker will contact them and provide the necessary general insurance advice and policy information. *
CLIENT DETAILS
*Name:
*Trading As:
*Occupation:
*Business Address:
*Contact Phone:
Fax No:
*Email:
Current Insurer:
Current Broker:
*Type of insurance to be discussed:
Date on which client can be contacted during business hours:
or Anytime:
Other information you may wish to provide to broker:
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