Please provide us with a breakdown of Number of Employees applicable to each State (must equal 100%)

By clicking the 'Submit' button you acknowledge and agree that your information will be handled in accordance with the Aon Privacy Notice, and you also confirm that:

• I/We confirm, that after enquiry of all personnel, I am not aware of any employment related claims being made against the Company within the last three (3), nor do I/we know of any potential circumstances or incidents which may give rise to a claim.
• I/We acknowledge that I/we have read, understood and agree to comply with my duty of disclosure obligations as set out in the Important Notices.
• I/We acknowledge that if this application is accepted, the insurance cover will be subject to the terms and conditions as set out in the Policy Schedule and Policy Wording.
• I/We declare that the information contained in this application form is true and correct and that I/we have not misstated any facts.
• I/We declare that the Company is a registered client of Workplace Assured as at the date of this insurance application and will maintain my/our Workplace Assured contract for the term of this insurance policy. If the contract with Workplace Assured ceases, I/we will provide written notification to Aon.
• I/We acknowledge that Aon values the privacy of personal information and is bound by the Privacy Act 1988 (Clth) when they collect, use, disclose or handle personal information.
• I/We acknowledge that Aon collects personal information to offer, provide, manage and administer the services they provide in accordance with Aon’s Privacy Statement. A copy of our Privacy Policy can be viewed at www.aon.com.au or alternatively, a copy can be sent to you on request. I/We consent to the use of my personal information for the purposes shown in the Privacy Statement, and the disclosure of my personal information to, and obtaining personal information from other parties, including the insurer, Insurance Australia Limited T/as CGU Insurance, as well as those shown in the Privacy Statement, for any of these purposes.
• If I/we have disclosed personal or sensitive information about any other person, I/we confirm that I/we have obtained consent from that person to disclose to you their personal or sensitive information and have made them aware that you will or may provide their information to other third parties, including the insurer for any of these purposes, and for the purposes, which we or the third parties may use the information for, including those outlined in Aon’s Privacy Statement. If I/we have not obtained consent and authorisation from any other person to disclose their personal or sensitive information to you, I/we will inform you before providing the relevant information.