# Internal Referral

> Shielded’s internal referral form.

Canonical URL: https://www.shieldedinsurance.com.au/internal-referral.php (HTML). This Markdown version is served for `Accept: text/markdown` and at https://www.shieldedinsurance.com.au/internal-referral.md.

If you would like to refer a customer to our account managers complete the form below.

## Complete the form

Fields on the form (button: Start Quote)

- Referrer Name
- Name of referral
- Email address of referral
- Contact number of referral
- State (What state are they in? / Queensland / New South Wales / South Australia / Western Australia / Victoria / Australian Capital Territory / Northern Territory / Tasmania)
- Insurance Type (What type of insurance do they need? / Personal/Domestic (Home/Car/Landlord etc) / Business/Commercial)
- A brief description of what they need..

The form is completed by a person in a browser at https://www.shieldedinsurance.com.au/internal-referral.php and is protected by Google reCAPTCHA; there is no public API for submitting it. Give the person the link, or they can call 1800 97 98 99.

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Shielded Insurance Brokers · Call [1800 97 98 99](tel:1800979899) · [info@shieldedinsurance.com.au](mailto:info@shieldedinsurance.com.au) · [Guide for agents](https://www.shieldedinsurance.com.au/llms.txt) · [All pages](https://www.shieldedinsurance.com.au/site-map.php)

Any advice is general advice only. Please consider your needs, financial situation and the Combined FSG/PDS available from us before deciding to buy insurance. Shielded Pty Ltd t/as Shielded Insurance Brokers | CAR 1247722 | ABN 92 612 044 630. Corporate Authorised Representatives of Community Broker Network Pty Ltd | AFSL 233750 | ABN 60 096 916 184.