workers compensation policy eft authority form

WORKERS COMPENSATION POLICY
EFT AUTHORITY FORM
Please complete this form to:
• receive payment from CGU via EFT into a nominated account
• nominate how you would like to receive notice of payments made (Remittance Advice)
I request that CGU Workers Compensation (NSW) Limited credit the nominated bank account with all due payments that relate to workers
compensation premiums (e.g. premium credits, overpayments).
Payee details
Registered business name
Address
Postcode
Policy number
ABN
Name of person completing form
Position
Remittance advice method
CGU are committed to reducing paper usage, and we encourage electronic communications where possible.
Email (nominate address)
Post
(as above)
Fax (nominate number)
Bank details
BSB number (must be six digits)
Account number
Name of financial institution
Name of account (which account is held)
Branch location
Authority
Office use only
I am authorised to provide the above details
Contact made to verify details
System details entered
Letter confirming details sent
Unable to verify
Signature
Completed by
Date
D D / MM / Y Y
Contact number (day)
Date
D D / MM / Y Y
Clear
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Ph: 1300 666 506
GPO box 9960, Sydney NSW 2001
[email protected]
WOR0816 REV1 5/15
Reviewed by
Date
D D / MM / Y Y
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CGU Workers Compensation (NSW) Limited
Agent for the NSW WorkCover Scheme
ABN 83 564 379 108/007