ACT Revenue Office
Department of Treasury	
Duties Act 1999

Application for General and Life Insurance Duty Registration
Under Sections 189 and 190 of the Duties Act 1999 insurers are required to be registered.

Client Reference Number 
	(If you are already registered with the ACT Revenue Office for any other tax or duty, please provide the client reference number supplied by this Office)		
TYPE OF REGISTRATION (DELETE CATEGORIES NOT APPLICABLE)

GENERAL INSURER	LIFE INSURER	GENERAL INSURANCE WITH  AN UNREGISTERD INSURER THROUGH AN INSURANCE INTERMEDIARY (BROKER)	
GENERAL AND LIFE INSURER	LIFE INSURANCE WITH AN UNREGISTERD INSURER THROUGH AN INSURANCE INTERMEDIARY (BROKER)	
COMPLETE THE FOLLOWING SECTIONS - A + B
SECTION A:  Insurer or Intermediary details – Name of Company, Association, Trustee, Partnership/Joint Venture or Individual (full legal name - if space is insufficient attach a separate sheet)

	

	

ABN		If applicable, the date the Australian Prudential Regulatory Commission authorised you to conduct new or renewal insurance business in Australia	

……../………/……….	

Trading Name or Trust Name		

ACT Business address  	
	
Postal address 
(for Service of Notices)	

Contact Officer		
Telephone		Facsimile		
Email address 		

SECTION B:
The ACT Revenue Office relies on the information provided in this application to register the insurer or intermediary under the Duties Act 1999.  Please make sure that the information provided is correct. 
The Criminal Code 2002 contains serious offence provisions for making, giving or producing false or misleading statements, information or documents for which the maximum penalty is 100 penalty units or imprisonment for one (1) year or both, and 500 penalty units or imprisonment for five (5) years or both if the false statement is knowingly made in a statutory declaration.
Declaration

I,_________________________________________ , ____________________________________________	
(full name)	(position)	
of ____________________________________________________________________________________	
(name of insurer or intermediary)	
declare that the information provided in this application is true and correct.	
Date:_____________________________________	Signature:__________________________________	

Forms and other information relating to insurance duty can be obtained from:  www.revenue.act.gov.au

Mail the completed forms to	ACT Revenue Office
PO Box 252
CIVIC SQUARE ACT 2608	
Or send by facsimile to	(02) 6207 0090	
Phone enquiries	(02) 6207 0079
(02) 6207 0088	
NOTE:
Notification of your registration will be processed within ten (10) working days of receiving the completed application.  Notification will be in the form of a letter or email and will advise you how and when to lodge the periodic returns and whether any further information is required to determine your liability.  If you receive assessments for any outstanding duty, they must be paid by the due date shown on the notices of assessment.

Privacy
The information in this form is required by the ACT Revenue Office to determine your ACT insurance duty liability and is authorised by the Duties Act 1999 and the Taxation Administration Act 1999.  The information can only be disclosed to another party in the circumstances outlined in the Taxation Administration Act 1999. In addition, personal information provided to the ACT Revenue Office is protected by the Privacy Act 1988 (Cwlth).  Information (including personal information) is not disclosed to any third party unless authorised by law or with the consent of the person involved.