Packager Application Form

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Packager insurance type required*

Packager Details

Packager company name*

Direct contact name*

Direct contact email*

Direct contact number*

Advisor Details

SFS advisor name*

SFS advisor email*

SFS advisor contact number*

Client Details

Business name*

Business primary contact*

Primary contact email*

Primary contact number*

Best time to contact (AM/PM)*

Insurance Requirements

Industry specialise in*

Commercial insurance type required*

Other insurance type*

Any important details to highlight?*

Type N/A if not applicable

Applicant Details

Applicant name*

Email*

Contact number*

Best time to contact (AM/PM)*

Insurance Requirements

General insurance type required*

Is there existing cover for insurance type required?*

Existing insurance details

Insurance type

Provider name

Renewal date (mm/yr)

Claims in last 5 years? (Y/N)

Any important details to highlight?*

Advisor Declarations

Tick only if the client has given consent for you to provide their details to a suitable packager and the packager has confirmed they can provide the relevant service to the client.

Advisor signature*