Referrer Application

General details

Percentage of Upfront & Renewal Commission:

Timeframe for Payment of Initial & Renewal Commission

I am not a representative or agent of General Insurance Brokers Of Australia Pty Ltd and for the purposes of making referrals to General Insurance Brokers Of Australia Pty Ltd I am not acting on behalf of General Insurance Brokers Of Australia Pty Ltd.
I have disclosed to General Insurance Brokers Of Australia Pty Ltd all information that is relevant to engage me as a Referrer.
I am of good fame and character and I do not have a criminal history nor have I been found guilty of any offence relating to dishonesty, serious misconduct or fraud.
I understand that General Insurance Brokers Of Australia Pty Ltd is committed to ensuring the confidentiality and security of personal information and that the information we supply will be used or disclosed solely for the purposes of assessing this application and to General Insurance Brokers Of Australia Pty Ltd to manage its obligations under the Corporations Act 2001.
I will disclose the commission earned for referring customers/clients to General Insurance Brokers Of Australia Pty Ltd at the time of making the referral either verbally or in writing (using the method by which the referral is made).

Signature

Completion of this form is not binding on any party and is subject to the completion and acceptance of a referrer agreement between all parties.

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