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Payment form

If we’ve recently sent you a communication about a payment you are entitled to or a notification about a cheque that is due to expire or has expired, please fill out the form below for us to provide your payment as quickly as possible.

If you do not complete this form, we may not to be able to provide you with your payment.

Your privacy and safety are important to us. To learn more about how we manage your personal information and how you can protect your details, you can read our Privacy Policy.

Please answer every question in this form.

Correspondence details

You can find your policy number and reference number on the top right-hand side of the letter or email we sent you.



Personal details

We need to collect the following information so that we can process your payment.

If your policy is in a business name, please put the full business name in both the first and last name field.




Refund to your bank account

We can only accept details for an Australian bank account.




Please ensure you have double-checked your bank account details as this will not be verified against any internal or bank records.

The information provided will be used for this payment only and we will not update any current policy or claim information.