Please resolve the following issues before proceeding

Click on an issue to go directly to the related section of the form.

errors found:

warnings found:

Declaration

Duties Form: Insurance Duty - Application for Registration as an Insurer

Fields marked with * are required

Collection statement

This information is collected by the SRO to establish your registration as an insurer under section 186 of the Duties Act 2000. If you do not provide the information required, we may not be able to process your application for registration and you may be liable for penalty tax. The information collected may be used for the purposes of other SRO legislation. Where authorised by law to do so, we may also disclose this information to other government agencies including the ATO, State and Territory revenue offices, and law enforcement agencies. You can find out more about how we use and protect your information in our Privacy Policy on www.sro.vic.gov.au.

Declaration

I declare that I am authorised to make this declaration.

The information provided on this form and in any attached documents is complete and correct. I understand that penalties apply for giving false or misleading information or omitting information.

The Electronic Transactions (Victoria) Act 2000 establishes the regulatory framework for transactions to be completed electronically. This form requires you to complete an electronic signature via tick-box before lodgment. By ticking the box you indicate your approval of the contents of this electronic communication.

Date

Signature

Date (DD/MM/YYYY)

First name

Middle name(s)

Family name

Position (if applicable)

Organisation (if applicable)

Mobile number

Phone number

Email

Applicant details

Duties Form: Insurance Duty - Application for Registration as an Insurer

Fields marked with * are required

Applicant details

Is the insurer an individual or a company?

Individual

Company

Name of insurer

First name

Middle name(s)

Family name

Name of insurer

ABN

ACN

Being an insurer within the meaning of section 184 of the Duties Act 2000 (‘the Act’), we apply for registration under section 186 of the Act.

Address of head office

Country

Australian address

What is the type of address?

Street

PO Box

Lot number

Floor/Level type

Floor number

Flat/Unit type

Unit number

PO Box number

Post office name

Lot number

Street number

Street name

Street type

Suburb/Town

State

Postcode

International address

Street address/Postal address

Suburb/Town

State

Postcode/Zipcode

Overseas Address

Australian Address

XMLAddress

XMLState

XMLPostCode

Is the postal address different from the above address?

Yes

No

Country

Australian address

What is the type of address?

Street

PO Box

Lot number

Floor/Level type

Floor number

Flat/Unit type

Unit number

PO Box number

Post office name

Lot number

Street number

Street name

Street type

Suburb/Town

State

Postcode

International address

Street address/Postal address

Suburb/Town

State

Postcode/Zipcode

Overseas Address

Mobile number

Phone number

Email

Application details

Duties Form: Insurance Duty - Application for Registration as an Insurer

Fields marked with * are required

Contact details

Specify the effective date for registration (DD/MM/YYYY)

Provide the details of the person(s) authorised to verify the returns lodged under section 190 of the Act:

Authorised officer

First name

Middle name(s)

Family name

Position

Mobile number

Phone number

Email