Actual Wages Declaration Form

Actual Wages Declaration Form

Please declare below the total actual wages paid during your previous period of insurance.
Name of Brokerage
Broker Email
If unknown, use info@repx.au
Details
Policy Number
Name of Insured
ABN
Business Activity
Actual Wages

Paid in your previous 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	Actual 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
Declaration
I, {name}, declare the above information is correct and I understand I may be subject to inspection of my wages books and other relevant records by an auditor appointed by the insurer.
Name

First NameLast Name
Signature
Date

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