Refer a Client

Name: Surewise
Address: PO Box 6095 Halifax Street, Adelaide, 5000, SA
Telephone: 1800 273 256

This page provides our network of referral partners with an easy and efficient way to send their new client referrals to our team of qualified and experienced insurance brokers.

If you are not a current referral partner and would like to become one, please contact our office on 1800 273 256.

Who are you referring to us?
This section of the form captures information about the client you are referring to SUREWiSE and will allow us to make contact with them.
Contact Person*
Enter the first name and surname of the person we should contact
First Name Surname
Business or Company Name
Enter the client's business or company name (if applicable)
Email Address*
Enter the contact person's email address
Phone Number*
Enter the contact person's phone number (including area code)
Website
Enter the client's website (if applicable)
Physical Address
Enter the client's physical address (if known)

Street Address Line 2 City State Post Code Country
Insurance Needs
This section of the form captures information about the type of insurance the client has client expressed an interest in. If the client is unsure, please select "unsure".
Identified Insurance Needs*
What type of insurance has the client expressed an interest in?
- Business Insurance
- Personal Insurance
- Vacant Land Insurance
- Unsure
Additional Information
This section of the form allows you to provide us with any additional information.
Enter any additional information you wish to bring to our attention.
Enter any additional information you wish to bring to our attention.
Referral Partner Details
This section of the form is used to identify you - our referral partner. We will contact you if we require further information. We will apply your unique referral partner code against the referral provided. If you do not know your unique referral partner code, please contact our office.
Referral Partner Code*
Enter your unique referral partner code
Referral Partner's Business Name*
Enter your business or company name
Name of Authorised Person*
Enter the first name and surname of the authorised person acting on behalf of the referral partner
First Name Surname
Authorised Person's Email Address*
Enter the email address of the authorised person completing this form
Phone Number*
Enter the contact person's phone number (including area code)
Authorisation & Declaration*
By ticking the box below, you declare that you have spoken to the client you are referring to SUREWiSE and the client has agreed for one of our qualified and experienced insurance brokers to contact them about their insurance needs. You also agree that the information you have provided us with on this form is complete and accurate to the best of your knowledge. You also acknowledge that referral partner rewards will only be considered if you have a current referral partner agreement with SUREWiSE which governs the referral agreement terms and conditions.
- YES - I confirm and agree with the above statement
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Email
This field is for validation purposes and should be left unchanged.

Refer a Client

Who are you referring to us?

Insurance Needs

Additional Information

Referral Partner Details

Information Resources