GIO Workers Compensation New South Wales. Policy Guide

GIO Workers Compensation New South Wales Policy Guide

Please note The information provided in this guide is for your reference. Please be aware that workers compensation legislation is frequently amended and it is important to obtain professional advice on your workers compensation responsibilities. GIO offers useful information on our internet site including quarterly newsletters. 1. Business activity WorkCover NSW requires every agent to obtain a full and precise business description from each policy holder at every renewal. Every agent is to classify a workers compensation policy based on the entire business or industrial activities undertaken by the employer. To ensure that your business is classified correctly we require you to supply a detailed description of all your business and industrial activities. The type of information we require includes: activities undertaken products involved materials used goods handled. Note: If you own or operate more than one business you must provide separate descriptions for each business. You also need to advise us whether or not these businesses rely on each other for their existence and if employees interchange between the businesses. 2. Definition of wages Wages declared in the Declaration of Wages form will be used to calculate your premium. The definition of wages for workers compensation is different to that in taxation legislation and is also different in each state/territory. Wages refers to the total gross earnings of your workers before you deduct tax. It includes: salaries and wages overtime, shift and other allowances over-award payments bonuses and commissions payments to working directors (including payments as directors fees) payments to certain contractors payments to piece workers payments for sick leave, public holidays and the associated leave loadings the value of any substitutes for wages grossed-up value of fringe benefits (allowances subject to fringe benefit tax are counted at the grossed-up value, that is the value of the benefit multiplied by the relevant Australian Tax Office benefit formula)* trust distribution to workers where the distribution is in lieu of wages for work done for the trust employer superannuation contributions (including the superannuation guarantee levy) long-service leave payments (including lump sum payments instead of long-service leave) termination payments (lump sum payments in respect of annual leave, long-service leave, sick leave and related leave loadings). It does not include as wages: directors fees paid to non working directors compensation under the Workers Compensation Act 1987 any GST component in a payment to a worker. * Non-profit organisations, public benevolent institutions (PBIs) and charities should continue to declare workers benefits that aren t subject to fringe benefit tax at the net value. Once the workers benefits exceed the Australian Tax Office fringe benefit threshold,the employer must declare the benefit at the grossed-up value. Per capita details instead of wages: Several Industry Classifications are based on a per capita rate rather than on wages paid. In this case, GIO requires you to supply the following information in lieu of wages so your premium can be calculated correctly. Industrial activity undertaken Taxi drivers and hire car drivers Professional boxers or wrestlers Professional footballers Jockeys or harness racing drivers Per capita details required Taxi or hire car registration number and the number of shifts for each registered plate Number of professional boxers or wrestlers and the number of bouts per boxer/wrestler Number of professional footballers and the number of games played per football player Number of jockeys/drivers and the number of mounts/drives per jockey/driver 1

3. Contractors Workers compensation insurance is compulsory for principal contractors when they engage subcontractors. You need to provide the following information for each contractor/outworker. Type of contracts are: 1. Labour only 2. Labour and hand tools 3. Labour and plant 4. Labour, plant and materials Worker or contractor A number of factors together determine whether a person is a worker or a contractor. All aspects of the engagement relationship between the employer and the hired person should be taken into consideration, in particular the terms of the engagement. Some key indicators in determining if a person may be a contractor include, but are not limited to: agreement is in writing work is quoted on a job-by-job basis the job has a start and end date payment amount is fixed for work performed and is made to a registered business entity and not an individual the person hired provides their own tools and equipment the person hired subcontracts or delegates the work the person chooses the hours they work and is able to offer their services to others a guarantee or warranty for the work performed is provided and rectification of defective work is provided at their own expense Having an ABN does NOT necessarily mean that the person is a contractor. Consideration must be given to the full nature of the agreement between parties. Deemed workers In some circumstances where a contractor is under the direction and control of a Principal contractor, the contractor may be deemed as a worker of the Principal (Schedule 1 Workplace Injury Management Act 1998). Deeming provisions apply to certain industries such as labour hire, outworkers, salespersons, canvassers and collectors, rural workers, timber getters, mine employees, boxers, wrestlers, referees and entertainers. A comprehensive list of deemed workers is contained under Schedule 1 of The Workplace Injury Management and Workers Compensation Act 1998. Worker Some key indicators that a person may be a worker include, but not limited to: payment for service is based on period of time worked. For example, hourly rate with payment made at regular periods, usually weekly or fortnightly. the person worked fixed or regular hours under the supervision and control of an employer employer provides materials/equipment the person performs work for the employer in accordance with an employment contract and takes no commercial risk work is performed personally and cannot be subcontracted to others employer provides tools unless specifically agreed the person receives paid leave. 4. Payment options For medium/large employers your annual renewal premium will be issued when GIO has processed your returned Declaration of Wages form. The premium will be shown on the premium calculation form and tax invoice. For small employers on the expiry of your current insurance period we will automatically accept your policy. The premium will be shown on the premium calculation form and tax invoice. Paying one full payment If your basic tariff premium is $1,000 or below, your annual renewal premium must be paid in one full payment. Large/medium employers who pay their annual premium in full by the due date will receive a 3% discount on their premium. Please refer to your account notice. Small employers who pay their annual premium in full by the due date will receive a 5% discount on their premium. Please refer to your account notice. 2

Paying by instalments NSW workers compensation legislation allows you to pay your annual premium by statutory instalments if: 1. Your period of insurance is 12 months 2. Your basic tariff premium exceeds $1,000 3. Your deposit instalment is received within 1 month after your renewal date. If this payment is received by the due date, GIO will issue an instalment schedule outlining your remaining instalments and their due dates. Failure to pay the instalments by the due dates will result in the forfeiture of your option to pay by instalments. Please allow for mailing delays. How to make payments BPAY refer to your policy documentation for your BPAY Payment Reference Number (PRN) or contact 13 10 10 to receive your BPAY Payment Reference Number. Credit Card You can pay with either VISA or MasterCard by calling us on 1300 735 282. A transaction Fee of 0.4% will apply. Direct Deposit BSB 032-000 Account Number 537672 Cheque or money order All cheques and money orders must be made payable to: GIO Please post all payments to: GIO Workers Compensation Policy Services GPO Box 3915 SYDNEY NSW 2001 In person by cash at any GIO or Suncorp branch Note: Please remember to include details of your policy number with your payment. Please refer to your Tax Invoice or Account Statement for further details. 5. GST GST legislation requires scheme agents to collect GST from their customers and remit it to the Australian Taxation Office (ATO). Businesses and non-profit organisations may be able to claim an input tax credit for the GST they have paid. To claim an input tax credit they must be registered for GST purposes with the ATO. If you have a registered business or non-profit organisation you must inform GIO of the extent to which you are entitled to input tax credits on your insurance premium. This advice is required before each insurance period or when you have a claim. If you do not provide this information it will be assumed that you are registered and entitled to claim 100% input tax credits for the GST paid on your premium. 6. Premium incentives The Apprentice Incentive Scheme provides a premium reduction for employers of apprentices. The Scheme aims to: grow the state s skill base encourage employers to hire apprentices improve workers compensation outcomes over time, because trained workers are less likely to be injured at work. This initiative commenced on 31 December 2006 and applies to new or renewed policies that commenced on or after this date. To be eligible you must have entered into a NSW Department of Education and Training (NSW DET) approved Training Contract with the apprentice in a designated trade vocation and the apprentice is identified in the training contract. (Note the reduction is available only to these apprentices and not to NSW DET recognised traineeships.) When renewing or obtaining a new workers compensation policy you are required to provide the amount of wages you pay your apprentice(s) and the industry in which they work separately from wages to other workers, on the wage estimate and declaration forms. This will allow your Scheme Agent to calculate your premium reduction. For further information contact: your workers compensation Scheme Agent, the WorkCover Information Centre 13 10 50 or visit www.workcover.nsw.gov.au 3

Employer Safety Incentive Effective 30 June 2013, employers receive a 10 per cent Employer Safety Incentive (ESI) premium discount up-front at each policy renewal. Make your workplace safe so that you have no workers off injured for more than four weeks during the policy period, and you can keep that 10 per cent when it comes time for your hindsight premium adjustment. Return to Work Incentive If you lose your ESI at any point in a policy period, your insurer will contact you about the Return to Work Incentive. Help all of your workers injured during the policy period return to pre-injury employment (with you or another employer) within 13 weeks, and you will still earn a 10 per cent reduction on your premium at hindsight adjustment. This aligns with the 2012 reforms, which structure weekly payments to encourage workers to return to work within 13 weeks. 7. Grouping of related employers Provisions for grouping for workers compensation purposes are set out in Divisions 2A and 2B of Part 7 of the Workers Compensation Act 1987. These provisions are also used to determine who is a related entity. All related employers that pay combined wages over $600,000 in NSW must be grouped for premium assessment purposes. However, charitable and not-for-profit organisations may apply to WorkCover for exemption to grouping status for those related employers who are not in direct competition with their private sector. All members of a group must have separate policies but must insurer with the same Scheme Agent, with a common renewal date for all policies. Groups with a combined basic tariff premium of $30,000 or less are eligible for the Small Employer incentives. Note: Grouping provisions commenced from 30 June 2006. For further information contact 13 10 50 or visit www.workcover.nsw.gov.au/workerscompensation/premiums/groupings 8. Cancellation If you wish to cancel your policy you are required by legislation to advise GIO in writing before the policy renewal date. GIO is not permitted to cancel a policy during a period of insurance except for when the business has ceased trading, has been sold or has been taken over by another corporation. If we do not receive written notification before the expiry date of your policy we are required (in accordance with WorkCover NSW guidelines) to automatically renew your policy. Please send your cancellation request to: GIO Workers Compensation Policy Services GPO Box 3915 SYDNEY NSW 2001 Tel: 13 10 10 Fax: 1300 666 346 9. Employer category Large and medium employers are employers with a basic tariff premium greater than $30,000. Small employers are employers with a basic tariff premium of less than or equal to $30,000 Certificates of Currency As an employer you may be required to provide a Certificate of Currency as documentary proof that you hold a current workers compensation policy. When you insure or renew with GIO we will automatically issue you a Certificate of Currency valid for up to 12 months from the date of issue or until the expiry date, whichever occurs first. Should you require an amended certificate of currency, you can complete the Employer Request for Certificate of Currency form through our GIO website www.gio.com.au/gio/workers-comp/forms-nsw.html. This form must contain an up-to-date business description, estimate of wages and number of employees for the policy year. 4

Guide to completing Declaration of Actual Wages form Please note: Effective 30 June 2013, there are two separate Declaration of Actual Wages forms for employers that are classified as small (those with a basic premium of $30,000 or below) and employers that are classified as medium and large (employers with a basic premium of $30,001 or above). The small employer version is shown below however the notes are also applicable to medium and large employers. SAVE AS PRINT AAI Limited trading as GIO Agent for the NSW WorkCover Scheme ABN 83 564 379 108-003 Claims: GPO Box 1464 Sydney NSW 2001 Ph: 13 10 10 Fx: 1300 733 677 Policies: GPO Box 3915 Sydney NSW 2001 Ph: 13 10 10 Fx: 1300 666 346 A Policy number Period of insurance From / / To / / WORKERS COMPENSATION ACT 1987 SMALL EMPLOYER DECLARATION OF ACTUAL WAGES C This form is to be used by small employers to declare the actual wages paid during the period of insurance stated above. Please complete this form in BLOCK letters and use a black pen. If further space is required, attach a separate page. Form Return Date: This form is to be completed and returned to your Scheme Agent no later than / / If the Return Date is blank, please note that in accordance with the Workers Compensation Regulation 2010, this form must be completed and returned to your Scheme Agent within four months following the end of the insurance period. If you wish to cancel your policy you are required by legislation to notify your Scheme Agent in writing before the expiration of the current period of insurance. 1 EMPLOYER S DETAILS 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) Postal address (if different from business premises) (PO Box or Street address) B Suburb Postcode Trading name Contact person ABN of employer or trustee (as applicable) Name of trust (if applicable) ACN/ARBN Phone Work ( ) Mobile Trust ABN (as applicable) Fax ( ) Email Location of business premises Street number Suburb Postcode D D1 2 ACTUAL WAGES FOR THE PERIOD OF INSURANCE If you are engaged in separate and distinct businesses, provide separate details of wages for each business activity in the section below. If no wages have been paid for the period, please indicate this by inserting the words Nil Wages. Note: Gross wages includes employer superannuation contributions. Refer to the notes under WAGES in PREMIUM FORMS DEFINITIONS for further information regarding other gross wages inclusions. If the actual wages for all your workers total $7500 or less per financial year, you are no longer required to hold workers compensation insurance, except where you engage an apprentice and/or a trainee, and/or are a member of a group. A. Direct workers Description of work performed Total no. of workers Total gross wages ($) Agent use (including apprentices) (including apprentices) WIC code D2 B. Details of apprentices included above (see note under APPRENTICE INCENTIVE SCHEME in DEFINITIONS) Description of work performed Total no. of apprentices Total gross apprentice wages ($) Agent use WIC code Page 1 of 2 A B C D D1 D2 This section provides your NSW Workers Compensation Policy Number and the period of insurance. This section outlines the date when you need to return this form to GIO. Section 1 Employer details outlines your business details including your business name, address and contact details. You need to check these details are correct and, if not, provide your current details. This will ensure the correct details are recorded on your policy. Section 2 Actual Wages for the Period of Insurance is to be completed with your actual wages paid for the period shown. A. Direct workers Direct Workers here you must state a description of work (i.e. retail), your total number of workers and gross wages for all workers (including superannuation, termination payment and apprentice wages if applicable). B. Apprentices only to be completed if you hire a NSW DET approved apprentice. Here you must state a description of work (i.e. installation ), number of apprentices and total gross wages for the apprentices only. 5

Guide to completing Declaration of Actual Wages form (continued) D3 D4 2 ACTUAL WAGES FOR THE PERIOD OF Policy number INSURANCE (cont.) C. Contract workers who are deemed to be your employees (see note under CONTRACTOR in DEFINTIONS) - record the full contract value in column (3) - an amount must be entered in this column. 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 (4), (5), (6) or (7). If these amounts are not known, place an X in the column that predominantly reflects 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) (3) Total no. of Full contract contract workers value ($) D. Non-wage based business activities No. of per Description - eg. taxi plates, rides, bouts, games, etc. capita units (4) (5) (6) (7) Labour only Labour and tools Labour and plant Labour, tools, plant ($) ($) ($) and materials ($) T: $ P: $ $T/P/M: $ T: $ P: $ $T/P/M: $ T: $ E. Asbestos P: $ $T/P/M: $ (8) Agent use WIC code D5 (see note under ASBESTOS in DEFINITIONS) Do you anticipate any of your workers in the course of their employment will handle, process or manufacture products containing asbestos? Yes No If you answered Yes, provide details of the activity/activities in which the worker/s will handle, process or manufacture asbestos-containing products. If insufficient space please attach a separate sheet. E 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 the average number of bailee shifts/ week per plate. Please provide this information on the supplementary form available from the NSW Taxi Council or on a separate sheet and then attach to this form. 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 above. In which industry are they employed? 3 BUSINESS ACTIVITY Please provide a clear description of your business activity and the goods/services you produce/handle/supply $ F 4 GROUPING OF RELATED EMPLOYERS G A - Grouping details Are you a member of a Group that pays combined wages in excess of $600,000 in New South Wales? (see note under Yes No GROUPING OF RELATED EMPLOYERS in DEFINITIONS) If No, complete the declaration (section 5). If Yes, have you registered with WorkCover as a member of a Group? Yes No If Yes, what is your Group Number? If you are a member of a Group and have not registered, go to www.workcover.nsw.gov.au to download a grouping registration form. If you have any questions about grouping, contact WorkCover on 13 10 50. B - Group changes including business acquisitions Have any related employers left or joined the Group during the relevant period of insurance? Yes No Have you purchased or taken over another company or part thereof within the last period of insurance? Yes No If Yes to either of the above, provide details below. If insufficient space please attach a separate sheet. Name of organisation that left/joined/was purchased ABN Scheme Agent Policy Number Policy Renewal Date Date left/joined/purchased (tick applicable category) Page 2 of 2 WC03975 0313 18315 CS 01/07/13 B Left Joined Purchased 5 DECLARATION BY EMPLOYER OR THEIR AUTHORISED REPRESENTATIVE I, PRINT NAME declare that the wages declaration which states the total wages paid to workers, details of apprentice wages, a description of the business activities and the number of workers employed for the period of insurance outlined above is made in accordance with the records required to be kept under the Workers Compensation Act 1987 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. Signature of person authorised to act on behalf of employer Date / / Position DEFINITIONS 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. DISCLAIMER 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 D3 D4 C. Contractors only to be completed if you have hired contractors. Here you must state a description of work (i.e. installation), type of contract and contractor, number of workers and total wages for the contract. D. Non-wage based business activities only to be completed if you own and operate Taxi Cabs, or if you are a professional footballer, jockey or boxer. D5 E. Asbestos only to be completed if you handle or are exposed to asbestos. E F G Section 3 Business activity is for you to provide a detailed description of your business activities. This should include a description of what your business does day to day, the services you provide and who your customers are (i.e. retail or wholesale). For example: The operation of a retail shop selling fruit and vegetables directly to the public. Section 4 Grouping of related employers is only to be completed if you are part of a group or wish to register for grouping. Section 5 Declaration is for the employer or an authorised representative to declare that all details in the Declaration of Actual Wages are true and correct. 6

Guide to completing Declaration of Estimated Wages form Please note: Effective 30 June 2013, only medium and large employers (those with a basic premium of $30,001 or above) are required to complete a Declaration of Estimated Wages form. SAVE AS PRINT AAI Limited trading as GIO Agent for the NSW WorkCover Scheme ABN 83 564 379 108-003 Claims: GPO Box 1464 Sydney NSW 2001 Ph: 13 10 10 Fx: 1300 733 677 Policies: GPO Box 3915 Sydney NSW 2001 Ph: 13 10 10 Fx: 1300 666 346 E: wcpolicy_nsw@gio.com.au A Policy number Period of insurance From / / To / / WORKERS COMPENSATION ACT 1987 MEDIUM AND LARGE EMPLOYERS DECLARATION OF ESTIMATED WAGES C This form is to be used by medium and large employers to provide an update of details for the renewal of the policy of insurance for the period stated above. Please complete this form in BLOCK letters and use a black pen. If further space is required, attach a separate page. Form Return Date: This form is to be completed and returned to your Scheme Agent no later than / / If the Return Date is blank, please note that in accordance with the Workers Compensation Regulation 2010, this form must be completed and returned to your Scheme Agent within two months of policy commencement. Failure to return the completed form in this timeframe will result in your policy being automatically renewed, with the renewal premium calculated using a 30% penalty loading on last year s estimated wages. If you wish to cancel your policy you are required by legislation to notify your Scheme Agent in writing before the expiration of the current period of insurance. 1 EMPLOYER S DETAILS 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) Postal address (if different from business premises) (PO Box or Street address) B Suburb Postcode Trading name Contact person ABN of employer or trustee (as applicable) ACN/ARBN Name of trust (if applicable) Phone Work ( ) Mobile Fax ( ) Email D D1 Trust ABN (as applicable) Are you registered for GST? Yes No If you are registered for GST, can you Location of business premises Street number claim back 100% of the GST from the ATO in your BAS return (ie your input Suburb Postcode tax credit entitlement is 100%)? Yes No If No, specify your reduced input tax credit entitlement % 2 ESTIMATED WAGES FOR THE PERIOD OF INSURANCE If you are engaged in separate and distinct businesses, provide separate details of wages for each business activity in the section below. Note: Gross wages includes employer superannuation contributions. Refer to the notes under WAGES in PREMIUM FORMS DEFINITIONS for further information regarding other gross wages inclusions. If the actual wages for all your workers total $7500 or less per financial year, you are no longer required to hold workers compensation insurance, except where you engage an apprentice and/or a trainee, and/or are a member of a group. A. Direct workers Description of work performed Total no. of workers Total gross wages ($) Agent use (including apprentices) (including apprentices) WIC code D2 B. Details of apprentices included above (see note under APPRENTICE INCENTIVE SCHEME in DEFINITIONS) Description of work performed Total no. of apprentices Total gross apprentice wages ($) Agent use WIC code Page 1 of 2 A B C This section provides your NSW Workers Compensation Policy Number and the period of insurance. This section outlines the date when you need to return this form to GIO. If you do not return this form by this date we are obliged to renew your policy using last year s wages increased by 30%. Section 1 Employer details outlines your business details including your business name, address and contact details. You need to check these details are correct and, if not, provide your current details. This will ensure the correct details are recorded on your policy. Section 1 also requires you to provide your GST status and Input Tax Credit entitlement. D D1 D2 Section 2 Estimated wages for the period of insurance is to be completed with your estimated wages paid for the period shown. A. Direct workers here you must state a description of work (i.e. retail), your total number of workers and gross wages for all workers (including superannuation, termination payment and apprentice wages if applicable). B. Apprentices only to be completed if you hire a NSW DET approved apprentice. Here you must state a description of work (i.e. installation), number of apprentices and total gross wages for the apprentices only. 7

Guide to completing Declaration of Estimated Wages form (continued) D3 2 ESTIMATED WAGES FOR THE PERIOD OF Policy number INSURANCE (cont.) C. Contract workers who are deemed to be your employees (see note under CONTRACTOR in DEFINTIONS) - record the full contract value in column (3) - an amount must be entered in this column. 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 (4), (5), (6) or (7). If these amounts are not known, place an X in the column that predominantly reflects 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 ($) D4 D. Non-wage based business activities No. of per Description - eg. taxi plates, rides, bouts, games, etc. capita units (4) (5) (6) (7) Labour only Labour and tools Labour and plant Labour, tools, plant ($) ($) ($) and materials ($) T: $ P: $ $T/P/M: $ T: $ P: $ $T/P/M: $ T: $ P: $ $T/P/M: $ (8) Agent use WIC code E. Asbestos D5 (see note under ASBESTOS in DEFINITIONS) Do you anticipate any of your workers in the course of their employment will handle, process or manufacture products containing asbestos? Yes No If you answered Yes, provide details of the activity/activities in which the worker/s will handle, process or manufacture asbestos-containing products. If insufficient space please attach a separate sheet. E 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 If Yes, estimate the above worker s total plate/s are metropolitan or country, and the average number of bailee shifts/ gross wages for the relevant period of week per plate. Please provide this information on the supplementary form exposure to asbestos. These wages must available from the NSW Taxi Council or on a separate sheet and then attach also be included in A and/or C above. to this form. In which industry are they employed? 3 BUSINESS ACTIVITY Please provide a clear description of your business activity and the goods/services you produce/handle/supply $ F 4 GROUPING OF RELATED EMPLOYERS A - Grouping details Are you a member of a Group that pays combined wages in excess of $600,000 in New South Wales? (see note under Yes No GROUPING OF RELATED EMPLOYERS in DEFINITIONS) If No, proceed to Section 5 CERTIFICATE OF CURRENCY OPTION If Yes, have you registered with WorkCover as a member of a Group? Yes No If Yes, what is your Group Number? If you are a member of a Group and have not registered, go to www.workcover.nsw.gov.au to download a grouping registration form. If you have any questions about grouping, contact WorkCover on 13 10 50. B - Group changes including business acquisitions Have any related employers left or joined the Group during the relevant period of insurance? Yes No Have you purchased or taken over another company or part thereof within the last period of insurance? Yes No If Yes to either of the above, provide details below. If insufficient space please attach a separate sheet. Name of organisation that left/joined/was purchased ABN Scheme Agent Policy Number Policy Renewal Date Date left/joined/purchased (tick applicable category) Left Joined Purchased 5 CERTIFICATE OF CURRENCY OPTION Do you require a Certificate of Currency to be issued based on the information you have provided in this Declaration of Estimated Wages? Yes No Page 2 of 2 WC05783 0313 18316 CS 01/07/13 B G 6 DECLARATION BY EMPLOYER OR THEIR AUTHORISED REPRESENTATIVE I, PRINT NAME declare that the information provided in this renewal and any attachments is true, correct and complete declare that no information has been suppressed or omitted from this renewal 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 Schedule 3 of the Workers Compensation Regulation 2010 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. Signature of person authorised to act on behalf of employer Date / / Position DEFINITIONS 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. DISCLAIMER 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 D3 D4 C. Contractors only to be completed if you have hired contractors. Here you must state a description of work (i.e. installation), type of contract and contractor, number of workers and total wages for the contract. D. Non-wage based business activities only to be completed if you own and operate Taxi Cabs, or if you are a professional footballer, jockey or boxer. D5 E. Asbestos only to be completed if you handle or exposed to asbestos. E F G Section 3 Business activity is for you to provide a detailed description of your business activities. This should include a description of what your business does day to day, the services you provide and who your customers are (i.e. retail or wholesale). For example: The operation of a retail shop selling fruit and vegetables directly to the public. Section 4 Grouping of related employers is only to be completed if you are part of a group or wish to register for grouping. Section 6 Declaration is for the employer or an authorised representative to declare that the details in the Declaration of Estimated Wages are true and correct. 8

Managing claims effectively If an injury occurs As an employer you are required to record all injuries or illnesses in your Register of Injuries. It is important that you notify GIO of any work-related injury or illness within 2 days of becoming aware of it. For serious incidents involving fatality or serious injury or illness, you must notify WorkCover NSW immediately on 13 10 50. The importance of early notification To notify GIO of a new claim you simply need to provide: your contact details your workers compensation policy number the worker s name, address, date of birth detail of the incident Early notification of an injury is vital for effectively managing the injury and achieving a safe, quick and durable return to work for the injured worker. The sooner GIO knows about the injury, the sooner we can provide assistance and develop a strategy to help return workers to their pre-injury duties, in turn reducing claim costs and workers compensation premiums. To avoid paying an excess, injuries must be reported to GIO within 5 days of notification from your employee. Contacting GIO Methods of notifying GIO of a workplace injury are: by phone to 13 10 10 Monday to Friday between 8.30am and 5.30pm EST by email to wcclaims_nsw@gio.com.au by fax to 1300 733 677 by post to: GIO Workers Compensation Claims GPO Box 1464 Sydney NSW 2001 Injury and Claims Management GIO will request a claim form together with a prescribed medical certificate, if and when they are required. The worker must nominate a treating doctor who will be responsible for the medical management of the injury. The doctor is required to participate in the development and implementation of the Return-to-Work program and Injury Management Plan. When you receive any documentation relating to a claim, please send it within 7 days with the claim number clearly marked to: GIO Workers Compensation GPO BOX 1464 Sydney NSW 2001 Claims excess The claims excess payment applicable for all employers will be the equivalent of 1 week of the injured worker s weekly entitlement to compensation benefits, as determined by Section 42 of the Workers Compensation Act 1987. The claims excess will be waived if the employer notifies GIO within 5 days of receiving notice of the injury. There is no claims excess applicable for Journey and Recess (authorised work break) claims. Health and safety responsibilities The Work Health and Safety Act 2011 legislation replaced the occupational health and safety (OHS) laws in NSW on 1 January 2011. These new work health and safety (WHS) laws will provide greater consistency, certainty and clarity across Australia making it easier to understand your workplace health and safety duties. Businesses and volunteer organisations that operate over several states will be able to initiate nationwide safety policies and procedures. Customer satisfaction Should you be dissatisfied with your NSW workers compensation policy or claims management, please let us know by calling 13 10 10. We will do our best to resolve the issue or complaint straight away or, if it requires additional investigation, within 5 days. If your complaint is not resolved to your satisfaction, GIO has an Internal Dispute Resolution process whereby your complaint will be reviewed by a specialist panel. In this instance, you will be notified of the review outcome within 15 days of your complaint being lodged. 9

How to contact us Phone: 13 10 10 Web: gio.com.au NSW Policies Email: wcpolicy_nsw@gio.com.au Fax: 1300 733 677 Post: GPO Box 3915, Sydney NSW 2001 NSW Claims Email: wcclaims_nsw@gio.com.au Fax: 1300 733 677 Post: GPO Box 1464, Sydney NSW 2001 AAI Limited trading as GIO Agent for the NSW WorkCover Scheme ABN 83 564 379 108-003. 09129 01/07/13 A