Your Details

This section of the form captures information about you so we can identify who you are and contact you to schedule a visit from one of our qualified and experienced insurance brokers.

Client Relationship*

Are you an existing SUREWiSE client?

Yes
No

Existing Clients

If you are an existing SUREWiSE client, what is your client code (refer to your invoice)?

Business or Company Name*

Enter your business or company name

Business Description*

What type of business do you operate and in what industry?

Contact Person*

Enter the first name and surname of the person we should contact

First Name Surname

Email Address*

Enter the contact person's email address

Phone*

Website

Enter your website address

Physical Address*

Enter the physical address for your business

Street Address Line 2 City State Post Code Country

Preferred Visit Details

This section of the form captures information about the nature of your request for one of our qualified and experienced insurance brokers to visit you.

Reason for Broker Visit*

What is the primary reason you require one of insurance brokers to visit you?

Insurance quote
Review current insurance programme
Insurance & risk management assessment
Insurance claim

Date of Visit*

What is your preferred date for a broker visit?

Time for Broker Visit*

What is your preferred time for a broker visit?

Morning
Afternoon
Evening

Authorisation & Declaration*

By ticking the box below, you acknowledge your request for a broker visit is a request only and SUREWiSE Pty Ltd (SUREWiSE) may not be able to arrange for one of our brokers to physically visit you or on your preferred date or at your preferred time. You also acknowledge that currently, SUREWiSE can only consider requests for a physical broker visit within South Australia (but note there are times when our brokers travel interstate). You also agree and declare that you are authorised to request a broker visit on behalf of the business or company you have named on this form and you agree to be contacted by one of our qualified and experienced insurance brokers.

YES - I confirm and agree with the above statement

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Comments

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