New South Wales Government

1. Provide the full name of the entity that is applying for this private ruling and ABN.

   1. ¤ Name:
   2. ¤ Date of application (dd/mm/yyyy):
   3. ¤ ABN:
2. Please provide details of your Workers Compensation Policy.

   1. Workers compensation policy number:
   2. Policy renewal date (dd/mm/yyyy):
   3. ¤ Agent (Insurer) with whom you hold the policy:
   4. Your principle business activity:

1. Who is the contact person for this application?
   (If it is you and you have entered your full name in Section A, enter 'as above' here).

   1. ¤ Name:
   2. ¤ What is your relationship to the entity (eg. director, partner, self, delegated officer):
2. Your contact number and email address.

   1. ¤ Your daytime telephone number:
   2. Your contact email address:
3. Address where you want the private ruling or other correspondence to be sent.

   1. Street address or PO Box:
   2. Suburb or town:
   3. State or Territory:
   4. Postcode:

Provide details of the person(s) or entity for whom this private ruling is for.

Note: A private ruling will only apply to the person (s) or entity named in the ruling and for the specified period. If you are unable to identify a fixed period, identify the event and start date for when this private ruling will apply.

1. Person or entity 1

   1. ¤ Name:
   2. ¤ Start date (dd/mm/yyyy) / Event:
   3. End date (dd/mm/yyyy):
   4. ABN:
   5. ACN:
2. Person or entity 2

   1. Name:
   2. Start date (dd/mm/yyyy) / Event:
   3. End date (dd/mm/yyyy):
   4. ABN:
   5. ACN:
3. Person or entity 3

   1. Name:
   2. Start date (dd/mm/yyyy) / Event:
   3. End date (dd/mm/yyyy):
   4. ABN:
   5. ACN:

The following checklist helps determine whether you have included enough information for the Authority to determine the private ruling.

Please complete each question to the best of your knowledge by selecting Yes or No from all relevant boxes.

1. ¤ Has the person(s) or entity for this request, to the best of your knowledge, currently or have they ever been subject to a wage audit on the issues raised by this ruling or been notified of a proposed audit?
   Yes

   No
2. ¤ Have you requested a private ruling on this matter previously?
   Yes

   No
3. ¤ Have you requested a s170 Premium Appeal on this matter previously?
   Yes

   No
4. ¤ Have you been the subject of a wage audit in the last 5 years or currently the subject of a wage audit?
   Yes

   No
5. ¤ Has the person(s), or entity for this request, lodged a workers compensation claim with you or may lodge a claim in the near future?
   Yes

   No
6. ¤ Is the person(s), or entity for whom you are seeking the ruling registered for GST?
   Please ensure ABN in Section C is completed
   Yes

   No

Please take the time to check that you have answered all the relevant questions.

1. A private ruling only relates to whether the person(s) or entity is a worker for premium calculation purposes. Provide a full description of the situation or circumstance that you require a ruling on.

   Please provide as much information as you feel necessary for us to make an accurate assessment Include all facts and attach any documents or evidence that support the information given to the Authority to determine the private ruling. Also attach the result of the worker status self-assessment tool used prior to completing this application.

   This field expands to accommodate the information you enter.

   ¤ Information about your situation or circumstance:

2. How do you think this person(s) or entity should be treated? Include references to relevant legislation, public rulings and case law where appropriate.

   This field expands to accommodate the information you enter.

   ¤ Your opinions and references (optional):

  Declaration

I am applying for a private ruling and I certify that the information contained in this document and any attached documents is true and correct.

I confirm that I have received the permission of the person(s) or entity for whom this private ruling is about to include their personal information on this application.

1. ¤ Your name
   (Authorised officer of the entity making this application):
2. ¤ Date (dd/mm/yyyy):

Please print this form and sign the Declaration under Section F: Consent and signature. You can then lodge this form via fax or post to WorkCover at :

Should you wish to discuss your application further, call WorkCover NSW on 13 10 50.