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Government Information
(Public Access) Act 2009
– application
Please complete this form to apply for formal access to government information
held by the State Insurance Regulatory Authority (SIRA) under the
Government
Information (Public Access) Act 2009 (GIPA Act). If you need help filling out this
form, please contact us using the details provided on page three.
Section 1: Your details
Given name(s)
Family name
If you are acting on behalf of another party, please provide their name here
Contact details
Postal address (include unit/street/property/Lot or DP/PO Box/GPO Box/Private Bag/Locked Bag)
Suburb
State Postcode
Primary contact number
Secondary contact number
Company
Email
Section 2: Proof of identity
If you are seeking access to any personal information (including your own), you will need to provide proof
of identity. Please attach a copy of any one of the following:
Current Australian driver’s licence
Current Australian passport
Other proof of signature and current address details
If you are completing this form on behalf of someone else, please attach evidence of your authorisation
to do so.
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Section 3: Government information
Please describe in detail the information you would like to access. Provide any additional information to
assist with the identification of documents.
Please attach any relevant documents if there is not enough space.
If you have applied to another government agency for substantially the same information, please provide
the name of the agency here.
Are there current legal proceedings relevant to your request for information?
Yes
No
Section 4: Consultation
Information that relates to other persons or businesses may require third party consultation before a
decision to release them can be made.
If third party consultation is required, the time taken to respond to your application will be extended by a
further 10 working days.
Do you consent for SIRA to provide your name when consulting with third parties?
Yes, I agree
No, I do not agree
Section 5: Disclosure log
If the information you have requested is released to you and would be of interest to other members of
the public, details about your application may be recorded in SIRA’s ‘disclosure log’. This is published on
our website.
Do you agree to this?
Yes, I agree
No, I do not agree
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Section 6: Payment of Fees
A $30 application fee must be paid when this application is submitted. Processing cannot proceed until
this fee is paid.
Payment type
Pay by cheque or money order. Enclose a cheque or money order made payable to SIRA.
Pay by EFT transfer. Please pay into the following account:
Reference: Your family name – GIPA
Account name: State Insurance Regulatory Authority
Bank: Westpac Banking Corporation
BSB: 032-001 Account number: 112713
A remittance advice must be sent t
o xxxx@xxxx.xxx.xxx.xx
Additional charges for processing the application ($30/hour) may apply.
Section 7: Privacy statement
We are collecting your information to process your application for access to information under the
Government Information (Public Access) Act 2009 (GIPA Act). You are not required to provide this
information, however if you do not provide it we may not be able to process your application.
This information will only be used to process your application. Your information will not be disclosed
without your consent or unless authorised or required under law.
Your information will be held by SIRA at McKell Building, Level 6, 2-24 Rawson Place, Sydney. If you would
like to access or amend the information we hold about you, please contact us using the contact details
provided below.
Section 8: Signature
Signature Date
(DD/MM/YYYY)
Section 9: Lodgement and contact details
Please post or email this application to:
State Insurance Regulatory Authority
Information Access
McKell Building
Level 6, 2-24 Rawson Place
Sydney NSW 2000
Email:
xxxx@xxxx.xxx.xxx.xx
Further information
For more information contact SIRA by: telephone 1300 656 919
, email xxxx@xxxx.xxx.xxx.xx or
visit www.sira.nsw.gov.au.
Catalogue No. SIRA08025
© Copyright State Insurance Regulatory Authority 0519
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