Certificate of Insurance

    First Name

    Last Name

    Policy Insured Name

    Preferred phone number

    Email Address

    Policy Number

    Item requiring proof of insurance

    Interested party (This is the company name that needs to be noted on the certificate)

    Where would you like us to direct this certificate?

    How would you like us to deliver this certificate?

    Attention to

    Please confirm you have the authority on this policy to request this information YesNo

    When do you require this Certificate of Insurance?

    Other comments

    Important Information
    Goldsworthy General Insurance Services Pty Ltd ABN 39 107 089 289 is an Authorised Representative of Resilium Insurance Broking Pty Ltd ABN 92 169 975 973 AFSL No. 460382
    We subscribe to and are bound by the Insurance Brokers Code of Practice, a full copy of which is available from the National Insurance Brokers Association (NIBA) website, www.niba.com.au
    This information does not take into account the objectives, financial situation or needs of any person. Before making a decision, you should consider whether it is appropriate in light of your particular objectives, financial situation or needs.

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