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Name of Business & FSRA Licence No.
Broker Code
Postal address
Email address
State	VICNSWQLDNTWASATASACTO/S
Contact Name
Contact phone number
Staff numbers/names
Are you a current NIBA member?	YesNo
Current book of Business
Value of the Book
Individual Travel
Corporate Travel
Group Personal Accident
Expatriate Medical
Actual value of current portfolio through us
Are you a IBNA broker?	YesNo
Are you a AUST broker?	YesNo
Are you a STEADFAST broker?	YesNo
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