myWorkCover Application Form

myWorkCover Insurance Application Form

My WorkCover Solutions Pty Ltd
ABN:13 656 574 533
PO Box 5612, Studfield Victoria 3152
Email: quotation@myworkcover.com.au
Phone: +61 421 128 139
Website: https://myworkover.com.au

Thank you for contacting myWorkCover Solutions for a Workers' Compensation insurance quote. Please complete all relevant fields so that we can provide you with a quote. If you need assistance completing the questionnaire, please speak with our Workers Compensation team on +61 421 128 139. If you choose to proceed with the application, we will use the information you provide to take out a new policy. Because WorkCover claims are backdated, WorkCover Authority in Victoria and South Australia have the authority to backdate the policy. Please ensure that the business's start date is backdated.

WorkCover claims in Queensland, New South Wales, Tasmania, the Australian Capital Territory, the Northern Territory and Western Australia are not backdated. Any claims filed prior to the inception of the policy will be treated as uninsured claims.

Completing myWorkCover application will enable us to understand your business structure. We can use this information to take out a policy in many states. However, depending on insurers in WA, NT, ACT and TAS you may require completing their own Workers' Compensation application. If so, we will pre-populate details on their forms, and you will need to sign them again.

As a part of our Policy Management service, we include the following:
- Renewal assistance – to ensure prompt renewal each year.
- Negotiate the terms on your behalf.
- We prepare your wage declaration form and submission and seek refunds.
- We ensure you have an updated Certificate of Currency each year.
- Mid-term wage and premium adjustments.
- Assistance in lodging any claims or incidents which occur within the policy period.
- 30 minutes of general WorkCover claims advice.
- We ensure that:
  - You are paying the correct premium.
  - We instruct your insurer on how to renew your policy.
- We review your classification for accuracy and look at ways to reduce your premium.
- As your Authorised Representative, we are here to assist you in all your needs throughout the year.
Rest assured; we have you covered!
Notice to the proposed Insured

This notice must be read before you complete the proposal form.

1. Disclosure of relevant facts - Your Duty of Disclosure

Before entering an insurance contract with an insurer, you are required by the Insurance Contracts Act 1984 to inform the insurer of anything you know or could reasonably be expected to know that may affect the insurer's decision to insure you and on what terms. You are responsible for this until the insurer agrees to insure you. You have the same obligation when renewing, extending, modifying, or reinstating an insurance contract.

You are not required to inform the insurer of the following:
- reduces the risk the insurer insures you for; or
- is common knowledge; or
- your insurer knows or should know as an insurer; or
- the insurer has waived your duty to tell them about it.
If you fail to inform the insurer of:

If you fail to inform the insurer of any required information, the insurer may cancel your contract or reduce the amount it will pay you if you file a claim or both. If you fail to notify the insurer, the insurer may refuse to pay a claim and treat the contract as if it never existed.

2. Claims made and notified policy

This insurance proposal is for a "claims made and notified" policy. This means that the policy covers you for claims made against you and reported to the insurer during the coverage period.

This policy does not provide cover in relation to:
- events that occurred prior to the retroactive date of the policy (if such date is specified). claims made after the expiry of the period of cover even though the event giving rise to the claim may have occurred during the period of cover;
- notified or arising out of facts or circumstances notified (or which ought reasonably to have been notified) under any previous policy; claims made, threatened, or intimated against you prior to the commencement of the period of cover;
- facts or circumstances which you first became aware of prior to the period of cover and which you knew or ought reasonably to have known had the potential to give rise to a claim under this policy;
- claims arising out of circumstances noted on the proposal form for the current period of cover or on any previous proposal form. Where you give notice in writing to the insurer of any facts that might give rise to a claim against you as soon as reasonably
3. Broker/Consultant acting as the agent of the insurer

In effecting this insurance contract, the broker or consultant will be acting under the authority given to it by the insurer, and the broker or consultant will be acting as an agent of the insurer rather than the insured.

4. Claims notification

If you become aware of a claim or circumstances that may result in a future claim, please notify us in writing as soon as possible so that we can notify your insurer on your behalf. If you become aware of a claim or 'circumstances' during the policy period and do not notify your insurer, you may be left uninsured or face a lower payout from your insurer for that claim or any future related claim.

5. Average provision

This policy provides that if a payment greater than the policy's limit of indemnity must be made to settle a claim, the insurer's liability for costs and expenses incurred with its consent shall be proportionate to the amount paid to settle the claim. Any excess will be deducted from claim payments.

6. Subrogation agreements

Where another person would be liable to compensate you for any loss or damage otherwise covered by the policy, but you agreed with that person either before or after the loss or damage occurred that you would not seek any monies from that person, the insurer will not cover you under the policy for any such loss or damage.

7. myWorkCover Privacy Policy

myWorkCover respects your privacy. Our Privacy Statement describes how we collect, use, and disclose personal information. This Privacy Policy document contains types of information that is collected and recorded by www.myworkcover.com.au accessible from https://myworkcover.com.au and how we use it. Our Privacy Policy can be found at https://myworkcover.com.au/privacy-policy or by contacting us. If you have additional questions or require more information about our Privacy Policy, please do not hesitate to contact us.

IMPORTANT NOTES
Volunteers are not regarded as workers. Employers of volunteers are not required to take out workers' compensation insurance for their volunteers but still have a duty to provide a safe working environment for them.

Employers that operate as sole traders or partners are not covered under the WorkCover Scheme in any state or territory in Australia. These policies will only cover their workers and contractors who are deemed workers under the “Contract Provision”. It is compulsory to take out a Workers' Compensation policy for employers who pay or expect to pay wages exceeding the minimum threshold in a policy period, or who hire apprentices or trainees to register for WorkCover Insurance.

The threshold could vary from state to state, but generally, it is $7,500.
- South Australia, it is $13,760 (indexed each year) for the 2022-23 financial year.
- New South Wales, Victoria and Queensland are $7,500.
- Tasmania, Western Australia, Nothern Territory and Australian Capital City have no threshold. You must take out a policy to cover your workers and contractors who are deemed workers.
You are not required to register for WorkCover if your wages are below the threshold in SA, NSW, VIC and QLD. However, if one of your workers is injured at work, you must contact us or the relevant state Authority to report the injury and at this time you will need to register and pay our minimum premium. The minimum premium varies in each state.

Company
A company is a body corporate that is registered under the Corporations Act. A company may be:
- A private company (generally indicated by ‘Proprietary Limited’ or ‘Pty Ltd’ in the name of
  the company) where the shares in the company are privately held; orA public company (generally indicated by Limited’ or ‘Ltd in the name of the company) where the public may purchase shares in the company.
A company exists by law independently of its shareholders. All companies have an Australian Company
Number (ACN).

Sole Proprietor
A sole proprietor is an individual who owns a business in their own name and is personally liable for its
debts.

Partnership
A partnership exists where persons or corporations carry on a business in common with a view to profit. A partnership may exist between individuals, between corporations or between individuals and corporations.

Apprentice & Trainee
If you hire any apprentices and/or trainees - even if you only hire one - you must register for WorkCover insurance, regardless of the size of your rateable remuneration. Some apprentices' and trainees' remuneration (including superannuation) are exempt from WorkCover insurance, so you need to be aware of the restrictions and qualifications that apply in each state.

Trustee & Trust
A trust is not a separate legal entity and cannot be an employer. Each trust has a trustee or trustees' responsibility for administering the trust. A trustee may employ people to assist in the administration of the trust. In such circumstances, the trustee is the relevant employer, and the policy will register the Trustee as the legal entity. However, in QLD, WA, NT, ACT and TAS the WorkCover Authority do recognise the Trust as the employer and may register the policy under the Trust as the legal entity.

Trainee exemption threshold
In Victoria, there is a cap on the amount of trainee remuneration that is exempt, and it is indexed each financial year. All other states have no trainee remuneration exemption and must declare to WorkCover Authority as per normal employee. Note that there is no cap on apprentice remuneration. This means you can only claim an exemption for your trainee's remuneration (including superannuation).

Other
This includes not-for-profit organisations such as cooperatives, incorporated associations, local government entities and statutory corporations. Please describe the nature of the organisation fully in the area provided.

ABN and ACN
The ATO issues the Australian Business Number (ABN). If you have one, it will include your ABN on
your tax invoice.

ASIC issues the Australian Company Number (ACN)
If you have one, it will include your A.C.N on your tax invoice.

GST status
Contact the ATO to find out if you should register for the GST.

Company directors or business owners
WorkSafe requires the full names of all directors or business owners to assist in applying the premium rule.

Minimum wage threshold & Minimum premium threshold
All states have a minimum premium. ACT, NT, TAS & WA there is no minimum wage threshold. VIC, SA, QLD & SA do have a minimum wage threshold.

Working directors & Contractors
Working directors and contractors are not covered in the state of Queensland. Working directors who are operating as an incorporated entity (company) will get cover in the State and Territory of Western Australia, Tasmania, Australian Capital Territory, Northern Territory, Victoria, New South Wales, and South Australia.

Working directors in Western Australia & Northern Territory
- Name & wages must be stated and specified when taking out the policy and at the renewal.
- The working directors in Northern Territory do not have an option to opt in or opt out of coverage
Working directors in Western Australia & Public Company
- Working directors have an option to opt in or opt out of coverage at renewal.
- Working directors of a Public Company cannot opt in & are not considered a worker under the Act.
Trust & Trustee
A business that operates through a Trust and the Trustee is an individual/partnership is not covered in any state. A Trust policy only covers its’ workers and contractors who are deemed workers under the “Contract Provision”. If you are unsure, please use the following link from the Australian Taxation Office (ATO) - A Guide to determine if your contractor is deemed a worker.

https://www.ato.gov.au/Calculators-and-tools/Employee-or-contractor

Trust Distribution
Trustees, directors, and beneficiaries are not deemed wages in any state, but if trust distribution is distributed to a working director in lieu of wages then it is considered wages and is rateable for WorkCover premium purposes.

Director's fee
If a director's fee paid to a working director is deemed as wages or it is in lieu of wages, it must be declared along with their wages to the WorkCover Authority for premium purposes.

Director's fee paid to a non-working director
If a director’s fee that is distributed to a non-working director, is not deemed as wages under the WorkCover Scheme and therefore is not rateable for WorkCover premium purposes.

Dividend paid to a working director
The profit that is distributed as a dividend at the end of the policy year is not considered wages, but if a dividend is distributed in lieu of wages, then it is deemed rateable for WorkCover premium purposes.

Applying for WorkCover insurance Guideline

Before completing the application, please ensure you have read:

Notice to the proposed Insured
IMPORTANT NOTES - this will assist you in completing the application form
When completing the application form:

Please complete the required fields and any questions that apply to you.
Refer to IMPORTANT NOTICE as this will help to answer any queries you may have.
For further information

If you need further help completing the form, or require advice, you can call us on +61 421 128 139. You can find further information on our website that will assist you in understanding the Workers' Compensation process and procedures.

Insured Legal Entity Name: (This name is usually the name that appears on all official documents or legal papers. The legal name may be different to the name you trade under.) *
(If sole trader or partnership, please provide full name including middle name)
Type of Entity: An employer usually sets up a business using one of the structures listed below. If you are a sole trader or an individual member of a partnership, then you are not a worker of your own business. However, if you have workers, you will need WorkCover insurance to cover them.*

Sole proprietorPartnershipsCompany (registered under Corporations Act)TrusteeOTHER (not-for-profit, cooperatives, incorporated associations, local government & statutory corporations. Please describe the nature of the organisation in the area provided.)
A.C.N (Australian Company Number):
ABN (Australian Business Number): Company / Sole Proprietor / Partnerships
Name of the Trust: (if your business is operating under a Trust)
(A Trust can be an Incorporated Entity (Company), Sole Proprietor or Partnerships)
Trust ABN (Australian Business Number):
(The ABN can be for an individual / partnerships / Company)
If the Trustee is a Company, please provide the A.C.N (Australian Company Number): (Because a trust is not a separate legal entity, it cannot employ people. A trustee or trustees manage each trust. A trustee may hire people to assist him or her in managing the trust. In such cases, the trustee is the proper employer. Refer to 'Important Notice')
If the Trustee is a Sole Proprietor or Partnerships, please provide your full name. If there are more than two in the Partnerships, please attach details on your letterhead.

First NameMiddle NameLast Name
Additional Name for Partnerships:

First NameMiddle NameLast Name

Business or trading name of workplace: (A business or trading name is the name that you trade under or the name by which your suppliers or customers know you. It may be different from your legal name).*
(If different from the Legal Entity name)
WorkPlace Address*

Street Number

Street Name

CityState / Province

Postal / Zip Code
Postal Address (if different from WorkPlace Address)

PO Box

Street No. & Street Name

CityState

Post Code
Preferred contact person for the policy: (We recommend the contact person be an employee or the business owner, not an external accountant or solicitor).*

First NameMiddle NameLast Name
Contact Email*
Office Phone Number

Area CodePhone Number
Business Mobile Number:*

Area CodePhone Number

	Example of relationship - common directors/shareholders, family relationship such as father, mother, sister, brother, uncle, aunty, etc.
State the relationship
Previous Business Name
Previous Policy Number
Australian Business Number (ABN)

	Please provide the details as this may impact on your current registration
Previous Policy Number
Previous Business Name
Australian Business Number (ABN)

	Note, each workplace can have different business activity, start date and its own workers. It is important that you provide accurate information for each workplace.
Commencement Date
Workplace Address
Business Activity
Estimate of Rateable Remuneration
Estimate Number of Workers

	Note, each workplace can have different business activity, start date and its own workers. It is important that you provide accurate information for each workplace.
Commencement Date
Workplace Address
Business Activity
Estimate of Rateable Remuneration
Estimate Number of Workers


General Employees
Contractors
Working Directors
Family Members
Apprentices
Trainees


General Employees
Contractors
Working Directors
Family Members
Apprentices
Trainees


Account Name
BSB
Account Number
Bank Name
Type of Account

DECLARATION: Print full name (using block letters)*

First NameLast Name
Clear
Print Title:*
Date of signing:*

DayMonthYear
Consent and declaration

False or misleading information

Before submitting this declaration, please ensure that you have provided all relevant information and that the information you have provided is true and correct. False or misleading information is a serious offence under the Workplace Injury Rehabilitation and Compensation Act of 2013, and it can result in severe penalties or imprisonment.
- I understand that the WorkCover Authority will evaluate this WorkCover Insurance registration based on the information provided in this form. I have read the questions on the form and understand the information I have provided.
- I have been authorised by the registrant to complete this form and sign this declaration on his or her behalf.
- The registrant certifies that all pertinent information was provided in response to the questions on this form and that the information provided is true and correct.
- The registrant declares that any personal information disclosed on this form, as well as any additional personal information provided in connection with WorkCover Insurance, has been or will be collected, used, and disclosed in accordance with all applicable privacy laws.
- The registrant agrees to the use and disclosure of any personal information collected on this form or provided further in connection with WorkCover Insurance for the purposes outlined in 'Collection of Personal Information.'
Collection of personal information

Personal information is collected by the Victorian WorkCover Authority (WorkSafe) or WorkSafe Agents on this form for the purpose of assessing your registration for WorkCover Insurance. Personal information collected on this form may also be used and disclosed for the purpose of administering and evaluating the WorkCover Insurance scheme and other related purposes. To fulfil these purposes, WorkCover Authority and its Agents may disclose the personal information collected on this form to each other, or to organisations such as other authorised Agents and service providers. If you do not provide any part or all of the information requested, your registration may not be processed. If you wish to access your personal information, you may contact the relevant WorkCover Authority in your state Freedom of Information officer or the WorkCover Authority appointed Scheme Agent. You can access WorkSafe’s Privacy Policy in each state. myWorkCover respects your privacy. Our Privacy Statement describes how we collect, use, and disclose personal information. This Privacy Policy document contains types of information that is collected and recorded by www.myworkcover.com.au accessible from https://myworkcover.com.au and how we use it. Our Privacy Policy can be found at https://myworkcover.com.au/privacy-policy or by contacting us. If you have additional questions or require more information about our Privacy Policy, please do not hesitate to contact us.
Should be Empty:

	Year 5	Year 4	Year 3	Year 2	Current Year
Number of Claims:
Total Cost of Claims:
Total remuneration
Insurer or Scheme Agent

	No	Yes	If yes, how many workers at any one time?
Aerial - Have you or any of your employees been on a single plane at the same time?
Underground Mine - Do you, your workers or contractors work at the Underground mine site?
Upper-ground Mine - Do you, your workers or contractors work at the upper-ground mine site?
Overseas - Do you, your workers or contractors work overseas?
Offshore - Do you, your workers or contractors work offshore?
Crystalline silica handling/generation of respirable crystalline silica - Do you, your workers, or contractors handle silica?

	No	Yes
Have you ever been charged or convicted of any criminal offence?
Has an insurer ever declined to offer you an insurance policy, or cancelled, refused renewal, or restricted cover under your previous insurance policies?
In the last 5 years have you been or are you currently bankrupt, insolvent, under administration, in liquidation or in receivership?

	Name	D.O.B	Phone	Email
1.
2.
3.
4.