RTBU App - Maurice Blackburn

Union rep name *

Union rep email *

Member's name *

Phone no. of member or next of kin *

Nature of enquiry *

Employer/Worksite *

Please specify nature of enquiry *

Will kit shipping address *

Shipping address 2 (Hidden)

Suburb *

Postcode *

State *

Number of will kits *

Other Information *

Nearest office *

Date and time of incident

Best time to call

Have you advised the member of this referral to Maurice Blackburn and do you reasonably believe the member will not object to being contacted? *

Yes
No