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Workers Comp Application Form  
Legal name of employer
(Your legal name may be different from your trading name. Give Company name,
Sole Trader or Partners’ full names. If a trust give the name of the trustee and the trust)Postal address (if different from business premises)
Location of business premises
Postal address (if different from business premises)
Phone Work
Registered company (eg. Pty Ltd company)
Name of Directors Address
Are you registered for GST?
If you are registered for GST, can you claim back
100% of the GST from the ATO in your BAS return
(ie. your input tax credit entitlement is 100%)?
If No, specify your reduced input tax credit entitlement

Did you establish this business?
Did you purchase this business?
Have you purchased or taken over another business or part
thereof within the previous 12 months?
If yes to the above, did you acquire additional
staff as a result of this acquisition?
(Note: it is compulsory for you to answer the above four questions)
Has this business or any business acquired (or part thereof) been insured for workers compensation in the past two years?
If Yes, complete details of previous workers compensation insurance coverage. If No, go to section 4.  
Insurance for previous two years
Last year
Period of insurance  
Year Before Last
Period of insurance  

To ensure correct premium calculation a detailed description is required for each separate and distinct business. Based on this description your Agent will assign a WorkCover Industry Classification (WIC) to enable calculation of your premium. To help describe your business, attach company brochures and website addresses.
Describe your business or industrial activity
- eg. I am a courier driver.
What goods/services do you produce/handle/supply?
- eg. I carry documents and small parcels.
What equipment/machinery/tools do you use in your business/industrial activity?
- eg. station wagon.
What specific trade qualifications and/or licences are required in your business/industrial activity?
- eg. driver’s licence.

If you are engaged in separate and distinct businesses, provide separate details of wages for each business activity in the section below.
Note: If the estimated wages for all your workers total $7500 or less per financial year, you are no longer required to hold workers
compensation insurance, except where you engage an apprentice and/or a trainee, and/or are a member of a Group. For an explanation as
to what gross wages specifically comprises refer to note under WAGES in DEFINITIONS.
A. Direct workers
Description of work performed Total no. of workers (including apprentices) Total gross wages ($) (including apprentices)

Agent use
WIC code

B. Details of apprentices – included above (see note under APPRENTICE INCENTIVE SCHEME in DEFINITIONS)
Description of work performed Total no. of workers (including apprentices) Total gross wages ($) (including apprentices)

Agent use
WIC code

C. Contract workers who are deemed to be your employees
(see note under CONTRACTOR in DEFINITIONS) - record the full contract value in column (3). Do not include any GST payable in this figure.
For the purposes of calculating contractor remuneration, enter further details re the breakdown of the full contract value into the $ value of labour
and other components (if known) into the applicable column/s (4), (5), (6) and/or (7). If these amounts are not known, place an ‘X’ in the column/s
indicating the components included in the contract without providing $ figures. DO NOT reduce the amount to reflect the standard default percentages referred to in the Wages Definition Manual. The agent will apply the default percentages as appropriate.
(1) Description of work performed (2) Total no. of contract workers (3) Full contract
value ($)
(4) Labour only ($) (5) Labour and tools ($) (6)
Labour and plant ($)
Labour, plant and materials ($)
Agent use WIC code
D. Non-wage based business activities
No. of per capita units Description - eg. taxi plates, rides, bouts, games, etc.
If you are a taxi operator, you will need to provide the following additional information: a list of plate/s held at the beginning of the period of insurance (including plate number/s), purchase/sale dates of
any plate/s that have changed hands in both the previous and current 12 months, indicate if plate/s are metropolitan or country, and theaverage number of bailee shifts/week per plate. Please provide this information on a separate sheet and attach to this form.
E. Asbestos
(see note under ASBESTOS in DEFINITIONS)
Do you anticipate any of your workers in the course of their employment will handle or becomeexposed to products containing asbestos? Yes No
If you answered Yes, provide details of the activity/activities in which the worker/s will be exposed to asbestos containing products.
If Yes, estimate the above worker’s total gross wages for the relevant period of exposure to asbestos.
These wages must also be included in A and/or C on page 2 of this form. In which industry are they employed?

Is your organisation related to or part of another organisation?
(eg. holding company, subsidiary. Refer to DEFINITIONS)
If Yes, provide details below. If insufficient space or if more than one related organisation, please attach a separate sheet.

Are you a member of a Group that pays combined wages in excess of $600,000 in New South Wales? (see note under GROUPING OF RELATED EMPLOYERS in DEFINITIONS)
If Yes, have you registered with WorkCover as a member of a Group?
If Yes, what is your Group Number?
If you are a member of a Group and have not registered, contact WorkCover on 13 10 50

Do you require a Certificate of Currency to be issued based on the information you have provided in this Proposal?

I, (print name),
  • declare that the information provided in this request and any attachments is true, correct and complete
  • declare that no information has been suppressed or omitted from this request
  • agree to supply a correct declaration of actual wages paid at the expiry of the period of insurance to allow an accurate calculation of premium. I understand the declaration of actual wages may result in further premium payable or a refund of premium paid
  • acknowledge that the terms and conditions of the policy are as prescribed by Form 3 of Schedule 1 of the Workers Compensation Regulation 2003
  • acknowledge that the Premium Forms Definitions supplement has been provided to me
  • consent to the information provided in this form, and any further information provided, be used for the purpose of evaluating and administering the employer’s workers compensation policy, and any related purpose
  • am authorised by the employer to complete this form and sign this declaration on behalf of the employer.

Penalties may apply for providing false, misleading or incomplete information.

To assist employers to complete this form a PREMIUM FORMS DEFINITIONS supplement is available separately. The DEFINITIONS supplement is common to the Insurance Proposal, Declaration of Estimated Wages, Declaration of Actual Wages and Request for Certificate of Currency and Statement of Wages forms. Please contact your Scheme Agent for the DEFINITIONS supplement if it has not been provided with this form. Employers are required to acknowledge that they have obtained the DEFINITIONS supplement when completing this form.
This form provides information and may refer to some of your obligations under the various workers compensation and occupational health and safety legislation that WorkCover NSW administers. To ensure you comply with your legal obligations you must refer to the appropriate Acts and regulations at www.legislation.nsw.gov.au
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