Licensee’s Workers Compensation Statement

Regarding:

Workers Compensation S175 B Workers Compensation Act 1987
Pay-roll Tax Schedule 2 Part 5 Payroll Tax Act 2007

Contractor/Licensee*

ABN*

has entered into a contract with the Royal Agricultural Society of New South Wales ABN 69 793 644 351

for work between:

Date from*

Date to*

Nature of contract work*

Declaration*

I am a Director or a person authorised by the Contractor on whose behalf this declaration is made.

I hereby state that the abovementioned entity is aware of and is adhering to the statutory obligations in regard to payroll tax and remuneration for work done under this contract.

I confirm the entity*:

Workers Compensation Insurance COC

I attach a copy of my Workers Compensation Certificate (COC) or other relevant insurance documentation in respect of work done in connection with the contract for the contract duration, and I have paid all Workers Compensation insurance premiums payable.

Please attach you valid Workers Compensation Insurance COC*

Voluntary Workers Personal Accident Insurance Policy

Please attach you current Voluntary Workers Personal Accident Insurance Policy*

Declaration

I confirm that if any of the work under this contract is subcontracted so as to make the company a principal contractor I will ensure a written statement is provided by subcontractors confirming their Workers Compensation insurance is in place in connection with the work.

I confirm that I am duly authorised to complete this form and provide information on behalf of the licensee* Confirm

First name*

Surname*

Email address*

Position/title*

Dated*

Warning:

• Any Contractor who knowingly provides a principal contractor with a written statement that is false is guilty of an offence (Maximum penalty 100 units or $11,000).
• Any written statement will not relieve the principal contractor of liability if at the time the written statement was provided the principal contractor believed the written statement to be false.
• Principal contractor must retain a copy of any written statement for a period of not less than seven years.
• This statement must be accompanied by the relevant Certificate of Currency to comply with 175B of the Workers Compensation Act 1987.

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