Allianz iClose Connection Request

Fill in the information below to request a connection to an Allianz product on iClose.

This form is for Insurance Advisernet use ONLY.

What is your Intermediary ID? (Please contact support@ebix.com.au if confirmation is required) *

Business/Company name? *

What is your company address? *

What is your company ABN? *

Are you an AR of another company? If so, what is the main company name?

Primary contact? *

Primary contact email address? *

What Broking System do you use? *

Please indicate which product from Allianz you wish to transact business with on iClose *

Business Pack (AALACOM)

Commercial Motor (AALAVSD)

Home Insurance (MMIHOP)

Landlord Insurance (AALLLP)

Motor Trades Pack (AALATSP)

Motor Vehicle Insurance (MMICMP)

Office Pack (AALAOFF)

Professional Liability (AALPLP)

Only select the following products if you operate out of Northern Territory (NT) *

TIO Business Pack (TIOACOM)

TIO Commercial Motor (TIOAVSD)

TIO Home (TIOCMP)

TIO Landlord (TIOLLP)

TIO Motor (TIOCMP)

TIO Motor Trades Pack (TIOAMPK)

TIO Office Pack (TIOAOFF)

TIO Trades Pack (TIOATSP)

Have you discussed this connection request with Allianz? *

If yes, who did you speak to?

Any other information Ebix should know?

ADDRESS

754 Pacific Highway, Chatswood 2067, NSW

PHONE / EMAIL

+61 2 8467 3000 / info@ebix.com.au

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