NSW Workers’ Compensation

Third Party Authority form.

Important Information.
Please take the time to carefully read this form before completing the relevant
parts and returning it to Allianz by post or fax. Once your completed form has
been received by Allianz, your nominated third party(s) will be able to contact
Allianz on your behalf.

Your Details:

Claim Number(s): Date of Birth: / /

Full Name: Telephone:

Address: Mobile:
Fax:

Third Party(s) Details:

1. Full Name: Date of Birth: / /

Address: Telephone:
Mobile:
Relationship: Fax:

2. Full Name: Date of Birth: / /

Address: Telephone:
Mobile:
Relationship: Fax:

Duration of Access: tick (✓) as appropriate

Third Party 1: 6 Months: 12 Months: The duration of the claim:

Third Party 2: 6 Months: 12 Months: The duration of the claim:

Declaration:
I, the undersigned:
• have read and understood this document, or have had this document read and explained to me and I understand its content;
• understand that in signing this document I give Allianz Australia Workers’ Compensation (NSW) Limited permission to release my personal
information to the above-named third party(s);
• understand that giving access means giving Allianz Australia Workers’ Compensation (NSW) Limited permission to provide the above-mentioned
third party(s) with access to my personal information;
• I understand that the above-mentioned third party shall have access for the duration I have specified above, and that such access shall expire at the
end of the period specified unless I notify Allianz in writing that I wish to revoke the third party access prior to expiration of the period referred to
above; and
• the third party referred to above has accepted responsibility for receiving access to my personal information.

Signature of Claimant:

✗
Date:
/ /

Please return completed forms to Allianz by post or by fax to: Allianz Australia Workers’ Compensation (NSW)
Limited, GPO Box 5429, Sydney NSW 2001 Tel: 1300 130 664 Fax: 1300 130 665