Commonwealth Numbered Regulations

1995 No. 317 LIFE INSURANCE REGULATIONS (AMENDMENT) - REG 6

6.1 Add at the end:
                                "FORM 3       Paragraph 10.05A (2) (a)

Life Insurance Act 1995
STATEMENT OF UNCLAIMED MONEY Year ended: Company: Contact officer: Telephone:

Policy number
Life insured: surname, given names, address
Policy owner: surname, given names, address
Amount due
Date amount became due
State where policy registered
Signed:                               Dated:
(Principal Executive Officer of the life company or a person authorised by the
Principal Executive Officer)
                               FORM 4         Paragraph 10.05A (3) (a)

Life Insurance Act 1995
STATEMENT OF MONEY PAID AFTER THE END OF THE CALENDAR YEAR Year ended:
Company: Contact officer: Telephone:

Policy number
Claimant: surname, given names
Date claimed
Date paid
Amount paid
Signed:                                     Dated:
(Principal Executive Officer of the life company or a person authorised by the
Principal Executive Officer)

                                FORM 5        Subregulation 10.05A (4)
Life Insurance Act 1995
UNCLAIMED MONEY DISK LODGMENT FORM Unclaimed money for year ended: Company:
Return address: Contact officer: Telephone: Number of disks: Creation date:
Original or replacement:
Number                              Value
Unclaimed policies at the end of the year: Policies claimed since the end of
the year: Certification: The information contained on the accompanying disks
is that required by section 216 of the Life Insurance Act 1995 as the
statement of unclaimed money, and money paid after the end of the calendar
year.
Signed:                                      Dated:
(Principal Executive Officer of the life company or a person authorised by the
Principal Executive Officer)".