Estimated Wages Declaration Form

Estimated Wages Declaration Form

Please provide an estimate of wages to be paid in the next period of insurance.
Name of Brokerage
example@example.com
Broker Email
If unknown, use info@remingtons.com.au
Details
Policy Number
Name of Insured
ABN
Business Activity
Estimated Wages

To be paid in the next period of insurance.
Period of Insurance: {from} to {date39}
From

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
To

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate

Employee Details:

Rows	No. of Full Time Employees	No. of Part Time Employees	No. of Casual Employees	Estimated Wages ($)
Clerical Staff
Sales Staff
General Employees
Working Directors*
Family Members*
Contractors/Subcontractors*

*Where details are completed for Working Directors, Family Members or Contractors/Subcontractors, please complete the corresponding table below:
Working Directors:
Family Members:
Contractors/Subcontractors:
CODES: LO – Labour Only LM – Labour and Material LPM – Labour, Plant & Material LP – Labour & Plant
Signature
Name

First NameLast Name
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Email
example@example.com
Should be Empty:

Estimated Wages