Ambulance Levy Registration

The Ambulance Levy is payable by private health insurance companies carrying out business in the ACT.  Private Health Insurers are required to register with the Commissioner for ACT Revenue.

Please complete the following form to register your company for Ambulance Levy with the ACT Revenue Office. All fields marked ( * ) are mandatory.

Section 1: Company Details










Section 2: Contact Details










Section 3: Ambulance Levy Details




If you are already registered with the ACT Revenue Office for a tax or duty, please provide the client number
previously supplied by this office.

Date services commenced? *

Section 4: Directors

List all directors, legal entity secretaries and officers showing full names, title and address






Section 5: Declaration


Declare that the information provided in this registration application is true and correct at the time of application.

I acknowledge that under section 338 of the Criminal Code 2002, giving false or misleading information is a serious offence and I will notify the ACT Revenue Office in writing and provide full details if there is a change in my circumstances during the financial year. This includes change of contact details, address or cessation of trading in the ACT.

Privacy Statement

All information collected by the ACT Revenue Office is protected by secrecy provisions in Acts administered by the Office and only used for the purposes of those Acts. In addition, personal information provided to the ACT Revenue Office is protected by the Information Privacy Act 2014.  Information (including personal information) is not disclosed to any third party unless authorised by law or with the consent of the person involved.

Contact us

If you require further information on the Ambulance Levy and your registration, please contact the ACT Revenue Office by clicking here or call us on (02) 6207 0028.