Renewal Declaration Commercial Motor

Do you need to renew your insurance?*

Yes, I need to renew my insurance
No, I no longer require this insurance

Name*

Company or trading name (Write N/A if not applicable)*

ABN

Phone Number*

Is your business based in NSW*

Yes
No

Over the next 12 months will your estimated turnover be:*

Under $2 million
Over $2 million

Estimated Turnover For The Next 12 Months*

Please note an increased turnover will generally increase the premium.

Estimated Payments to Sub-Contractors For The Next 12 Months*

Number of employees (including yourself)*

Have your or do you expect your occupational activities to change from the occupation description noted in your current insurance schedule and/or have you changed your business name or structure with ASIC?

What is the current depreciated market value of your vehicle/s for this year.

Vehicle 1 Make and model*

Vehicle 1 Value*

Vehicle 2 Make and model

Vehicle 2 Value

Vehicle 3 Make and model

Vehicle 3 Value

Vehicle 4 Make and model

Vehicle 4 Value

Vehicle 5 Make and model

Vehicle 5 Value

In the last 5 years have you had any criminal convictions, been bankrupt, do you have any unreported claims or incidences that you may claim against, had any insurance declined or variations imposed or anything else that may affect your insurance that we should disclose to the underwriters?*

Yes
No

Do you require quotes or further information on these insurance products?*

Management Liability (OH&S, Fairwork, ATO, ACCC & ASIC Investigation and legal costs cover)
Home & Contents Insurance
Tools cover
Vehicle Insurance
Life or Income Protection Insurance
Cyber Liability (Cover against hacking and being held to ransom by Cyber criminals)
Other (Please describe Below)
Additional Quotes Not Required

Amount of tools cover required*

We offer finance broking as one of our services. Do you require pricing on any loans or finance?*

What type of finance do you require?*

Additional Information

GUIDELINES TO SIGNING THE NSW STAMP DUTY EXEMPTION - SMALL BUSINESS DECLARATION What is the NSW small business exemption? From 1 January 2018, NSW small businesses will be exempt from paying stamp duty on certain types of insurance. What is a small business? Revenue NSW has stated that: “You are a small business if you are an individual, partnership, company or trust that is carrying on a business, and the business has an aggregated turnover of less than $2 million. Aggregated turnover is your annual turnover plus the annual turnovers of any business entities that are your affiliates or are connected with you.” Which insurance types will the exemption apply to? This exemption can be applied for NSW small businesses with one the following insurance types: • Commercial vehicle insurance • Commercial aviation insurance • Occupational indemnity insurance • Product and public liability insurance Instructions for applying for an exemption To receive the exemption, please complete this declaration declaring that you / your client are a small business. Email the completed declaration to [email protected]. Please note: [a] This declaration covers all policies issued to you during the financial year ended 30 June 2021. [b] If you are uncertain whether you classify as a small business, please speak to your financial adviser. [c] Brooklyn Underwriting will place reliance on your declaration in charging the applicable insurance duty. [d] False declarations may result in penalties up to of $11,000 by Revenue NSW plus the insurance duty not paid and penal interest on that balance. [e] Revenue NSW may also be able to clarify your queries relating to the law and your obligations. [f] If you are a not for profit organisation already entitled to a NSW Stamp Duty Exemption, your premium is already exempt and the NSW Stamp Duty Exemption for Small Business is not relevant.*

I earn under $2 million p.a. and qualify to have my stamp duty removed
I do not qualify for this exemption