T eration.

Workers' Compensation Declaration of Actual Remuneration

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

The Workers' Compensation Act requires you to provide the wages for the past year so that your premium can be calculated to determine whether you are entitled to a credit refund or pay the gap difference.

Please submit your last year's actual declaration of remuneration as soon as possible or within 4 months of the expiry date of your policy.

It is important to note that if you do not declare your actual (certified) Rateable Remuneration, your insurer will be assessed/deemed your last year's remuneration to finalise the policy period. Generally, the deemed amount is at least 20% more than your estimated remuneration. An Underestimation Penalty may apply when Rateable Remuneration is not certified or is incorrectly certified.

Refer to myWorkCover Remuneration Matrix to determine your remuneration.

Legal Entity Name:*

Policy Number:*

Please select the state:*

Your Last Policy Renewal Date:*

Your actual remuneration for the last policy period.*

Rows	Actual Wages	Workers: Full-time	Workers: Part-time/ Casuals
Gross Salary/Wages
Superannuation Guarantee Contributions (Employer contribution)
Superannuation Contributions (Employee contributions)
Termination Payments (in lieu of notice of accrued leave & benefits)
Redundancy payments (accrued leave etc.) Only declare if your policy is in ACT or NSW
Redundancy payments (accrued benefits) Only declare if your policy is in ACT, TAS or NSW
Contractors (Deemed Workers)
Fringe Benefits Tax (FBT) – Gross up figure
Other Benefits & Bonuses
Director’s fees paid (non-working). Only declare if you are in Victoria and Tasmania.
Director’s fees paid (working director). Note: exemption in Queensland as the director is not covered and is not deemed a worker in the Act.
Profit sharing schemes (bonus in lieu of wages)
Allowance - Meal/Overtime/Shift/Tool/Travel/Award Over Payments, etc.
Lump sum payments in lieu of holiday, sick leave, or long service leave.
TOTAL:
Apprentices (Gross Wages and Superannuation). Apprentices are exempt from the premium calculation in VIC, NSW, QLD, and SA. However, wages paid to an apprentice must be declared to the insurer.
Trainees (Gross Wages and Super). Trainees are only exempt in VIC with a threshold (index each year) from the premium calculation. Wages paid to the accredited trainee must be declared to WorkSafe Victoria. If the trainee’s wages are above the threshold, the wages will be treated the same as normal wages that are paid to a normal worker. Please declare this value and myWorkCover will determine if it is required to declare to WorkSafe Victoria.

Declaration and Agreement (you must complete this section)

I/We acknowledge that I/We have read the notice to the proposed insured on the reverse of this proposal and understand those notices. I /We acknowledge that if this proposal is accepted by the insurer, the insurance cover will be subject to the terms and conditions as set out in the policy wording.

I/We declare that the information above is true and correct and that I/We have not suppressed nor misstated any material facts.

Print Full Name (using block letters):*

First NameLast Name

Contact Number*

Please enter a valid phone number.

Email*

Please provide a valid email.

Signature of person authorised to act on behalf of the employer:*

Date of Signature *

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.

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