Workers Compensation Form
Your Details
Full name: (incl Title)
*
Contact telephone number:
*
Email address:
*
Business Details
Name of business: (legal entity)
*
Business address:
*
Postcode:
*
Business type:
*
Estimated wages:
Number of employees:
Please provide full details of any claims made and/or losses suffered under previous Workers Compensation Insurance during the past 5 years (whether or not a claim was made):
*
If none, please state
Please use this box to provide any further information that may be relevant to your Workers Compensation Insurance policy :
Current Workers Compensation Insurance provider:
*
If none, please state
Current Workers Compensation Insurance premium:
*
If none, please state
Renewal date of existing insurance/date cover to start (as applicable):
*
NB: Cover is not in force until agreed upon by the company
Contacting You
Are you an existing Dental Essentials customer?
*
yes
no
Preferred contact method:
*
Please select
Telephone
Email
Letter
Preferred contact time:
Please select
No preference
08:00-10:00
10:00-12:00
12:00-14:00
14:00-16:00
16:00-18:00
How did you hear about us?
*
Please select
Referred by friend
Referred by another business
Referred by another website
Search engine
Advertising
Dental Essentials is a trading name of Bourchier Nominees Pty Ltd. We would like to contact you from time to time about products and services (or with news, offers and promotions) that we feel may be of interest to you. By providing us with your contact details, you consent to being contacted by these methods for these purposes.
Please tick the box if you prefer to
not
to receive marketing communications from us by post or telephone.
Please tick the box if you prefer to
not
receive marketing communications from us by email, text messaging or other electronic means.