If you want to seek an exemption, complete and submit this form.
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Mandatory
Policy Number:
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Date:
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Relevant person (name of the insured person effecting or renewing the contract of insurance):
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Email address (so we can send you a copy of the declaration):
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At the time that the contract of insurance is effected or renewed (as applicable), I am or will be a small business as defined in section 259A of the Duties Act 1997 (NSW) for the purposes of the small business exemption in section 259B of the Act.
I declare the above as the relevant person or if not the relevant person, on their behalf.
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Submit