IP Authorisation

I authorise my employer to deduct from my post-tax earnings the weekly premium of $50.43 which is to be remitted directly to PROTECT (ABN 98395 548 596) on my behalf and I aim to be simultaneously reimbursed via payroll for that same amount.
Furthermore, I authorise the amount of the deduction to be increased from time to time,on the condition that the amount reimbursed by my employer to me is of the same amount.
I authorise my employer to provide my name, address, contact details and date of birth to PROTECT for the purpose of administering my income protection insurance.
I authorise the insurer to provide to my employer a breakdown of my income protection insurance premium for the purpose of compliance with taxation requirements.
I understand the income protection insurance administered by PROTECT, will come into effect on 1 January 2023 at 4pm if duly signed and dated authority and declaration is received by PROTECT before that date or otherwise as at the date that this duly signed and dated authority and declaration is received by PROTECT.
I understand that the amount reimbursed by my employer is not deductible in my personal income tax return and nor will that amount be reported as income on my annual payment summary.
I understand that this declaration is to apply for a period of up to five years from the date of this declaration or until a new declaration is sought from my employer to otherwise comply with taxation requirements or I otherwise withdraw this declaration.

First Name *

Last Name *

Date of Birth *

Email Address *

Mobile *

Address *

Street address *

Suburb *

State *

Postcode *

Registered / Payroll Number *

Employer *

Date *

Signature *

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On submission your form will be sent to Protect, with copies provided to you, your employer and ATC Insurance Solutions.