Application for General and Life Insurance Duty Registration Form
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

GENERAL INSURER

LIFE INSURER

GENERAL INSURANCE WITH AN UNREGISTERED INSURER THROUGH AN INSURANCE INTERMEDIARY (BROKER)

GENERAL AND/OR LIFE INSURER

LIFE INSURANCE WITH AN UNREGISTERED INSURER THROUGH AN INSURANCE INTERMEDIARY (BROKER)

INSURERS 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 Person:		
Telephone:		Facsimile:		
Email address:		

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. The ACT Revenue Office relies on the true and correct information provided in this application to register the insurer or intermediary under the Duties Act 1999.  
Your application will be processed within 10 working days of receiving this completed application form.  Information regarding the process to lodge and pay periodic returns will also be included.  For any assessments issued with an outstanding amount of duty, they must be paid by the due date given on the assessment to avoid penalties and interest.

GIVING FALSE OR MISLEADING INFORMATION IS A SERIOUS OFFENCE (Criminal Code 2002)	
Privacy Statement - All information collected by the ACT Revenue Office is protected by secrecy provisions in Acts administered by the Office and only used for the purposes of those Acts. In addition, personal information provided to the ACT Revenue Office is protected by the Information Privacy Act 2014. Information (including personal information) is not disclosed to any third party unless authorised by law or with the consent of the person involved.	

Revenue Office Contact Details
Telephone	(02) 6207 0028	
Email	dmr@act.gov.au	
Facsimile:	(02) 6207 0090	
Postal address	PO Box 293
Civic Square  ACT  2608	
Website	http://www.revenue.act.gov.au