Victorian Numbered Regulations

METROPOLITAN FIRE BRIGADES (CONTRIBUTIONS) REGULATIONS 2009 (SR NO 63 OF 2009) - SCHEDULE 2

SCHEDULE 2

Sch. 2

Metropolitan Fire Brigades Act 1958

Regulation 6

PREMIUM RETURN FOR THE YEAR ENDED 30 JUNE

Under section 40 of the Metropolitan Fire Brigades Act 1958

The portion of the total amount of gross premiums received by or due to—

Name of Company:     ACN/ABN:

of Address:

Billing Address:

Contact Name:                 Tel. No.:

Email:

during the financial year ended 30 June (including any commission or discount) compiled in conformity with the prescribed portions of premiums properly attributable to insurance against fire in respect of property within the metropolitan fire district as set out in Schedule 4 of the Metropolitan Fire Brigades (Contributions) Regulations 2009 is $ [ in words to the nearest dollar ]. This amount was calculated from the following information—

Column 1	Column 2	Column 3	Column 4	Column 5	Column 6
Item	Classes of insurance subject to contribution	Total amount of premium received or due in Victoria	Total amount of premium received or due outside Victoria or overseas	Total of columns 3 and 4	Amount of premium subject to contri-bution
1	any insurance on property that includes insurance against fire (whether expressly or otherwise and

Column 1	Column 2	Column 3	Column 4	Column 5	Column 6
Item	Classes of insurance subject to contribution	Total amount of premium received or due in Victoria	Total amount of premium received or due outside Victoria or overseas	Total of columns 3 and 4	Amount of premium subject to contri-bution
	whether or not extended to include other risks) and includes consequential loss, business interruption insurance or other similar classes of insurance but does not include any insurance of a class specified in item 2, 3, 4, 5 or 6	$	$	$	$
2	any insurance on property construction or engineering installation or both that includes insurance against fire (whether expressly or otherwise and whether or not extended to include other risks) and includes

Sch. 2

Column 1	Column 2	Column 3	Column 4	Column 5	Column 6
Item	Classes of insurance subject to contribution	Total amount of premium received or due in Victoria	Total amount of premium received or due outside Victoria or overseas	Total of columns 3 and 4	Amount of premium subject to contri-bution
	consequential loss, business interruption, contractors' plant and machinery insurance or other similar or associated insurance	$	$	$	$
3	any insurance that solely covers risks that otherwise would be insured under item 1, 2 or 6	$	$	$	$
4	domestic and residential insurance but excluding where rated separately and offered and given as an optional extra all premiums received for personal property or personal items insurance or both that must be included under item 5	$	$	$	$

Sch. 2

Column 1	Column 2	Column 3	Column 4	Column 5	Column 6
Item	Classes of insurance subject to contribution	Total amount of premium received or due in Victoria	Total amount of premium received or due outside Victoria or overseas	Total of columns 3 and 4	Amount of premium subject to contri-bution
5	any insurance that solely covers personal property or personal items or both (excluding any insurance of a class specified in item 1, 2, 3, 4 or 6)	$	$	$	$
6	the static risk portion of the premium for any marine class of insurance or any other class of insurance that is confined to perils of the sea or air or confined to risks involving transportation on land or in the air (excluding storage incidental to transportation by sea, land or air)

Sch. 2

Column 1	Column 2	Column 3	Column 4	Column 5	Column 6
Item	Classes of insurance subject to contribution	Total amount of premium received or due in Victoria	Total amount of premium received or due outside Victoria or overseas	Total of columns 3 and 4	Amount of premium subject to contri-bution
	(static risk includes all movements of goods, stock or material associated with processing or storage operations at any place)	$	$	$	$

I [ insert name ] am the *Manager/Secretary/Agent of the Company and I declare that according to the books of the Company and to the best of my knowledge and belief this return contains a true statement of the amount of gross premiums received by, or due to, the Company during the preceding financial year.

I further declare that in accordance with section 40(4) of the Metropolitan Fire Brigades Act 1958 the amount of fire service levy collected by the company in the financial year ended 30 June in the year totals $ for items 1, 2, 3 and 6 and $ for items 4 and 5.
Sch. 2

I acknowledge that this declaration is true and correct and I make it in the belief that a person making a false declaration is liable to the penalties of perjury.

Declared at     this     day of         in the year     before me [ insert name ], a person authorised to take a statutory declaration in the place where this declaration is made.

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* delete if not applicable

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