Triathlon QLD App

1. js-submit-data-layer
2. TQ rep name
3. TQ rep email
4. Member's name
5. Member's phone number
6. Nature of enquiry
7. Employer/Worksite
8. Suburb
9. Post code
10. State
11. Please specify nature of enquiry
12. Other Information
13. Nearest office
14. Date and time of incident
15. Best time to call
18. Have you advised the member of this referral to Maurice Blackburn and do you reasonably believe the member will not object to being contacted?
19. Web User ID
20. CAPTCHA

TQ rep name

TQ rep email

Member's name

Member's phone number

Nature of enquiry

Select an enquiry type Injured at work Injured in a road accident Exposed to asbestos Need to make a super claim Injured by medical treatment Injured in a public place Will dispute Free legal advice Other

Employer/Worksite

Suburb

Post code

State

Select... ACT NSW NT QLD VIC SA TAS WA

Please specify nature of enquiry

Other Information

Nearest office

Nearest office Brisbane Browns Plains Bundaberg Caboolture Cairns Darwin Gold Coast Ipswich Mackay Rockhampton Strathpine Sunshine Coast Toowoomba Townsville

Date and time of incident

Best time to call

Best time to call Morning Afternoon Evening

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

Web User ID

Submit