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Membership Inquiry Form

Contact Name:
Phone Number:
including Area Code
Email Address:
Broker Details
Trading Name:
AFSL No.:
ABN:
Years in Operation:
Company Information
Total GWP 2007/08:
(excl $ sign and commas) 		$ 
Total Brokerage 2007/08:
(excl $ sign and commas) 		$ 
PI Limit of Indemnity:
(excl $ sign and commas) 		$ 
NIBA Member: Yes  No
Member of another Cluster group: Yes  No
If Yes, please specify:
Broking Software Program:
CBS   Winbeat   Other  
If Other, please specify:
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