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Product Information
Claim
About
Work Experience Insurance
Because accidents do happen
Get a Quick Quote and Take Out Cover Immediately
Enter the details of the Work Experience Participant.
First Name:
*
Last Name:
*
Email:
*
Contact Phone:
*
Date of Birth:
*
Address:
*
Suburb:
*
State:
Please select...
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
8499
Postcode:
*
Period Required:
Please select...
15 days cover - over 3 months
30 days cover - over 6 months
30 days cover - over 12 months
60 days cover - over 12 months
3 months - unlimited
6 months - unlimited
9 months - unlimited
12 months - unlimited
9901
What type of work will you be doing?
Please select...
Manual (i.e. labour/hazardous activity)
Non-Manual (i.e. office work)
10215
Will you be engaging in any of the following activities:
Underground mining; Offshore work; Horse Riding; Sporting Activities; Naval, Military or Air Force Activities, work involving the use of any Weapons or Ammunition, Racing.
I declare:
Please select...
I will NOT be
I will be
10263
Where did you hear about Experience Worx?
Please select...
Rehab Provider
Search Engine
Social Media
Existing Customer
Referred by a friend
Broker
Other
10059
Referrer Name:
Referrer Company:
58F3D6A3-EE55-B85D-F2FBB91EBBC835F7
8499
8/11/2024
2
* Indicates a mandatory field.