Worklife Contractor Declaration

PRIVACY STATEMENT

i2i Brokers are bound by the obligations of the Privacy Act 1993 regarding the collection, use, disclosure and handling of your personal information. We will protect the privacy of your personal information. We will use the information you provide in this Declaration Form to consider your application for insurance under Worklife's Indemnity programme, to determine any special policy terms, to assess a claim, etc.

We will disclose this information to Worklife's Indemnity insurer, Delta Insurance who will use your information for the purposes we provided it to them (or if required by law)

Lets get to know you

Your full name

Your best contact number for you if we need to discuss your Declaration

Please advise your Email address

When does your contract with Worklife start?

What best describes the role you are doing while on assignment with Worklife?

If you trade as a Limited Company please advise the company name here:

What are your responsibilities while on this assignment?

Who are you contracting to while on assignment with Worklife (the name of the Client)?

Prior history

Declaration

I am authorised to make this Declaration

I have read this Declaration and acknowledge the contents is the same and to be true and complete.

After enquiry, I the undersigned, declare (insert your name in the box below)

I agree that this Declaration supplied by me/us shall form the basis of any contract of insurance effected thereon, and I undertake to inform the Insurer of any material alteration to these facts whether occurring before or after completion of such contra

I agree that i2i Brokers may use and disclose our personal information in accordance with the "Privacy Statement" at the beginning of this Declaration.

By ticking this box you agree you have signed your approval of the information disclosed and the use of I/We Accept is as reliable as is appropriate given the purpose for which, and in the circumstances in which a signature is required

THIS FORM NEEDS TO BE COMPLETED IN ITS ENTIRETY. Cover will not be provided unless all questions have been answered. Incomplete Declarations will be sent back for resubmission.

i2i Insurance Brokers