Group Insurance Application Form

ANZ gateway THIS ONLINE FORM ACCEPTS CREDIT CARD PAYMENTS ONLY.

You will be directed to the ANZ eGate secure payment facility after you have submitted your form.
If your payment is successful, your transaction receipt number will appear below.
You will also receive a confirmation email, which includes a copy of your receipt number and the information you have provided on the form.

QuiltNSW does not collect nor store any credit card information in conjunction with this payment facility.

Group Insurance Form 2022/2023

Application for Public Liability Insurance for QuiltNSW Member Groups for 1 JULY 2022 – 30 JUNE 2023

Please complete your renewal of group membership for 2022/2023 BEFORE completing this form. RENEW ONLINE

This application must be read in conjunction with the following documents:

For any further information, please e-mail: insurance@quiltnsw.com

Group Name(Required)

Group Membership Number

Name of Contact Person(Required)

First Name Family Name

Postal Address(Required)

Street Address City State Post code

Preferred phone contact(Required)

Email(Required)

Date of renewal for group membership for 2022-2023 financial year(Required)

Required Disclosures

Has your group made any insurance claims in the past three years?(Required)

Yes

Has your group had any criminal offences or been declared bankrupt in the past 5 years?(Required)

Yes

Have any insurers refused coverage to your group or offered it only on special terms?(Required)

Yes

If yes, please provide details(Required)

Max. file size: 128 MB.

Group Membership List(Required)

Drop files here or

Max. file size: 128 MB.

Please upload your list of names of your members in alphabetical order by Family Name.

Additional Coverage

Please tick ALL that apply

our group requires public liability coverage for exhibition(s) in 2022/2023

Our group requires additional equipment insurance

Our group rents premises from an entity who has asked to be noted as an "Interested Party" on our policy?

Date of exhibition(s)(Required)

Exhibition venue(s)(Required)

Expected visitor numbers per exhibition(Required)

Additional Equipment Insurance(Required)

Please include details for a quote

Landlord name(Required)

eg Northern Beaches Council

Premiums

For standard public liability insurance cover, the premium is based on the number of members in your group calculated at $7.50 per person.

Group Members (Required)

Price: $ 7.50

Enter the total number of members in your group

Exhibition Public Liability Coverage (Required)

Price: $ 50.00

$50 per exhibition

Total

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