REQUEST FOR POTENTIAL ECONOMIC LOSS CALCULATION

Contact Details

Return report to
Contact Name:
Company:
Address:
Phone:	Fax:
Email:
Your reference:

Personal Details

Name:

Date of Birth:

Sex:

Start Date of Loss:

End Date of Loss (default age 65):

Discount to (default today's date):

Benefit Details

	7% Discount 0% p.a. Inflation
	3% p.a. Discount 0% p.a. Inflation
	Other - if so please write details below
Discount               % p.a.               Inflation               % p.a.

Salary Information

Please complete from the start date of loss to the end date of loss with the first and last years showing actual earnings for the part year - not the annual rate of earnings.
This salary information is: Gross Earnings    Net of Tax and Medicare Earnings
Year	Amount	Year	Amount	Year	Amount	Year	Amount
1950/51		1951/52		1952/53		1953/54
1954/55		1955/56		1956/57		1957/58
1958/59		1959/60		1960/61		1961/62
1962/63		1963/64		1964/65		1965/66
1966/67		1967/68		1968/69		1969/70
1970/71		1971/72		1972/73		1973/74
1974/75		1975/76		1976/77		1977/78
1978/79		1979/80		1980/81		1981/82
1982/83		1983/84		1984/85		1985/86
1986/87		1987/88		1988/89		1989/90
1990/91		1991/92		1992/93		1993/94
1994/95		1995/96		1996/97		1997/98
1998/99		1999/00		2000/01		2001/02
2002/03		2003/04		2004/05		2005/06
2006/07		2007/08		2008/09		2009/10
2010/11		2011/12		2012/13		2013/14
2014/15		2015/16		2016/17		2017/18
2018/19		2019/20		2020/21		2021/22
2022/23		2023/24		2024/25		2025/26
2026/27		2027/28		2028/29		2029/30
2030/31		2031/32		2032/33		2033/34
2034/35		2035/36		2036/37		2037/38
2038/39		2039/40		2040/41		2041/42
2042/43		2043/44		2044/45		2045/46
2046/47		2047/48		2048/49		2049/50

Contingencies

Nil i.e. certain payment
With allowance for average mortality
With allowance for average workplace participation

Comments / Special Items

Actuarial Fees

$440.00 (inclusive of GST)
Invoices will be forwarded with report.

Please forward this document to Brian Bendzulla at:
Bendzulla Actuarial Pty Ltd, GPO Box 1181, Hobart TAS 7001
Fax 1800 103 123   Tel 1800 203 123
Email: actuarial@bendzulla.com  

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