Victorian Application for WorkCover Insurance

Victorian Application for WorkCover Insurance

Need Help? Call (03) 9234 3285

Do I need insurance?

If you expect to pay more than $7,500 a financial year in rateable remuneration, or if you have any apprentices or trainees, you must take out WorkCover Insurance. This applies even if you are a small company with only one worker.

indicates mandatory information.


Cover Page
Employer Details
Business Details
Workplace Details
Consent & Declaration
Your name:
Contact number:
Email:
Name of your accountant, bookkeeper or broker:
Your accountant or broker's telephone number:
Your Allianz intermediary ref# (if known):
Please nominate which Allianz office you wish to manage your Workers’ Compensation business:

Need help?

If you require assistance in filling out this form, please telephone us on (03) 9234 3285.

Allianz Australia Workers’ Compensation (Victoria) Limited ACN 059 853 791

Phone: (03) 9234 3285

Employer Details

 1) Name of your WorkSafe agent:
Allianz Australia Workers’ Compensation (Victoria) Limited
 2) Legal name of employer:
 3) Type of entity:
Please provide details of the Type of Entity:
 4) Your ABN:
     ACN:
 5) Have you registered / intend to register for GST?
 6) Company Director(s) or business owners name(s):
7a) Contact person name:
 b) Contact person position:
c) Mailing Address:
     Postcode:
     Suburb:
d) Mobile and/or Landline:
    
e) Email:
f) Website:

Business Details

8) Why are you making this application?
(tick any that apply)
If other (please specify)
9) Employment commencement date:
10) Do you wish to take out the buy-out option?
11) Have you purchased or taken over an existing workplace or business?
a) Legal name of previous employer:
b) WorkSafe employer number:
c) What is your relationship to that employer?
12a) At any time, did any person (or any of their associates) who has a direct or indirect interest in your business also have a direct or indirect interest in the workplace you have purchased or taken over?
12b) At any time, did any person (or any of their associates) who has a direct or indirect interest in your business also have a direct or indirect interest in a business that is connected, associated or related to the workplace you have purchased or taken over?
13) Does any of your staff primarily provide services to another business?
14) Are the operating requirements of your business substantially supplied to you by one other business?
15) Do you have a holding or subsidiary company?
16) Do you or any entity that substantially influences the running of your business have a substantial influence over the operations of another business?
17) Does your business RECEIVE all the goods produced or services provided by another business?
18) Does your business SUPPLY its goods or services to less than four other businesses?
19) Is your business involved with any other business or with businesses represented together as a single business?
Please provide details of other businesses:

Business name
WorkSafe Employer Number

Workplace address

Postcode
20) Have you been notified by the State Revenue Office of Victoria that you are a member of a group under the Pay-roll Tax Act 1971?

Workplace Details

21) How many workplaces do you have?
22) Business or trading name:
23) Physical address of workplace:
     Postcode:
     Suburb:
24) Workplace commencement date:

Your activity and revenue/costs

25) What do you consider is your main activity in this workplace and why?
26) List the key goods or services that you intend to produce or provide at the workplace:
27a) List the key types of raw materials used to produce or supply the goods or services:
27b) List the key classes of equipment used to produce or supply the goods or services:
27c) List the key types of processes used to produce or supply the goods or services:
28) Do you own the goods you sell?
29) Does this workplace supply goods or services mainly or wholly to any other workplace in your business?
a) Please provide a workplace address:
     Postcode
30) Do you have substantial dealings with a business that shares or that neighbours your workplace?
31) Revenue and costs for the next twelve months:

Product / service Sales /
revenue
Goods sold /
Services provided
Cost of labour  
$ $ $

$ $ $  

$ $ $  

$ $ $  

32) Estimate of rateable remuneration:

Please include salaries and wages, any contractors deemed to be your workers, grossed up value of fringe benefits, other remuneration and superannuation in your estimate.
Total current year Total next year  
     
$ $  
33) How many workers do you expect to employ for this year?
Full Time Part Time Apprentices/Trainees
34) Estimate exempt remuneration for apprentices
and/or trainees:
Current Year Next Year  
 

Consent and Declaration

Collection of personal information

Personal information is collected by WorkSafe or WorkSafe agents for the purpose of assessing your application for a WorkSafe Insurance Policy. Personal information collected on this form may also be used and disclosed for the purpose of administering and evaluating the WorkSafe Insurance scheme and other related purposes. To fulfil these purposes, WorkSafe or Allianz may disclose 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 application may not be processed. If you wish to access your personal information, you may contact the WorkSafe’s Freedom of Information officer or Allianz.

You can access the WorkSafe Privacy Policy at www.worksafe.vic.gov.au.

False or misleading information

Before completing his declaration, it is important that you ensure you have provided all relevant information and that the information provided is true and correct. To provide false or misleading information is a serious offence under the Accident Compensationm Act 1985 and the Accident Compensation [WorkCover Insurance] Act 1993 whcih can result in you incurrring severe penalties or imprisonment.

  • I understand that WorkSafe will assess this application for WorkSafe Insurance on the basis of the information provided in this form. I have understood the questions set out in the form and understand the information which I have provided.
  • I am authorised by the applicant to complete this form and sign this declaration on behalf of the applicant.
  • The applicant declares that all relevant information has been provided in answer to questions on this form and that the information given is true and correct.
  • The applicant declares that any personal information disclosed on this form and any further personal information provided in connection with WorkSafe Insurance has been or will be collected, used and disclosed in accordance with applicable privacy legislation.
  • The applicant consents to the use and disclosure of any personal information, which is collected on this form or further provided in connection with WorkSafe Insurance, for the purposes outlined in ‘Collection of Personal Information’.

Full name of person completing this application:
Job Title:
Contact No:
Date: