REQUEST FOR POTENTIAL SUPERANNUATION LOSS CALCULATION

Contact Details

Return report to
Contact:
Firm:
Address:
Tel:	Fax:
Your reference:

Personal Details

Name:

Date of Birth:

Date of Accident:

Date from which Superannuation Contributions Ceased:

Intended Retirement Age: 65 / 60 / 55 (circle one) Other:

Wage at Accident Date (gross p.w.):

Current Wage (gross p.w.):

Discount to this Date (Default today's date):

Benefit Details

	SG Contribution - Large Employer ( > $1 million payroll )
	SG Contribution - Small Employer ( < $1 million payroll )
	Other - please attach details

Comments / Special Items

Actuarial Fees

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

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

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