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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Profits from every event held at Sydney Showground are invested back into supporting Australian agriculture and rural communities. That's because it's the venue hire business of the Royal Agricultural Society of NSW (RAS), a not-for-profit organisation dedicated to contributing to the agricultural prosperity of New South Wales.

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