Consent(Required) I/We apply to be a Referrer for the Landcover Insurance Product provided by the Issuing Parties named below and warrant that: I am/ We are not a representative or agent of the Issuing Parties and for the purposes of making referrals to the Issuing Parties are not acting on behalf of the Issuing PartiesI/we have disclosed to the issuing Parties all information that is relevant to the engagement as a Referrer.I am/ We are of good fame and character, and do not have a criminal history nor have I/we been found guilty of any offence relating to dishonesty, serious misconduct or fraud.I/We understand that the Issuing Parties are committed to ensuring the confidentiality and security of personal information and that the information supplied will be used or disclosed solely for the purposes of assessing this application and to enable the Issuing Parties to manage its obligations under the Corporations Act 2001. I/We understand that the referral arrangement will commence following approval of this Application, and the granting of a website Referral link which can be provided to customers for the purpose of referral to the Landcover website and agree to disclose the Referral Fee (if applicable) as stated in the Referral Fee Disclosure requirement below.Landcover Issuing Parties: Multi- Functional Policies P/L T/as MFP Insurance Brokers AFS License 241685 and Underwriting Authority Holder and Landcover P/L T/as Landcover as their Authorised Representative 311341 and Landcover Product Issuer.Name of ApplicantName (Company or Individual)(Required)Date of Birth (Individuals only)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ABN of Applicant (if applicable)Are you Registered for GST?(Required) Yes No Principal Business Address(Required) Street Address Suburb State Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia Postcode Email Address(Required) Phone(Required)Main Contact Person and Telephone(Required)NamePhoneBank details for payment of Referral feesBank NameAccount NameBSB NumberAccount NumberSelect the occupation that best describes your business(Required)Select one...AccountingAssociations/OrganisationsAFSL General Insurance BrokerASIC registered Authorised RepBuilders- LicencedBuilding DemolishingCommunity Title/ Strata ManagersFinanceLand Agents/SalesLand ConveyanceLand DevelopmentLand ManagementLand Sub-DivisionLand ValuersLandscaping/ClearanceLegal /Trustee/Executor servicesPool Sales/installationShed / Container sales /installationTrades ContractingOtherPlease State(Required)The Australian Financial Services Licensee for Landcover is required to advise customers when they apply to purchase a Landcover Policy from a link that has been given to them, that a Referral Fee maybe paid. Landcover’s online policy application states that any Referral Fee paid by them is a marketing expense and is not an additional cost to the Policy.Landcover offers to pay to Referrer’s who agree to accept the Landcover Referral Fee Offer, an agreed referral fee amount of $20.00 + GST $2.00 for each Landcover Policy purchased by a customer using the provided website Referral Link.Referrer’s can choose to DECLINE or ACCEPT the offer to be paid a Referral Fee however there is a Fee Disclosure requirement that has to be made.Fee Disclosure: The Referrer agrees to comply with the Licensee’s requirement to disclose at the time of making the referral, either verbally or in writing (using the method by which the referral is made), that a Referral Fee of $20 plus GST or $2.00 ( if the Referral Fee Offer is declined) fee will be paid by Landcover when the website link provided is used to purchase a Landcover Policy.The Referral Fee amount can be varied by Landcover giving the Referrer 30 days notice in writing*A Referral Fee will only be paid when customers use the website Referral link provided to apply and pay online for a Landcover Policy using the Landcover website. No Referral Fee will be paid for any Policy that is not successfully issued online nor for any Policy cancelled during or after the 21 day “Cooling Off” Policy provision when Landcover agrees to refund the amount paid by the customer. Referral Fees will be paid 30 days after the end of the month in which the policy was paid.I/We ACCEPT/DECLINE the Offer to be paid a Landcover Referral Fee and agree to comply with the $20.00 plus GST/$2.00 Fee disclosure requirement of the Licensee.(Required) Proceed and receive a referral commission Proceed with no referral commission Referral IDNameThis field is for validation purposes and should be left unchanged.
