S175C Private ruling form

  • 1 Section A: Your Details
  • 2 Section B: Your contact details
  • 3 Section C: Details of whom this private ruling is about
  • 4 Section D: Initial assessment checklist
  • 5 Section E: Your question/s and facts
  • 6 Section F: Consent and signature

Use this form to request a private ruling on the worker status of a person or group of persons for premium purposes.

Required fields are marked with an asterisk (*).
Section A: Your Details

 

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

Date of application *

 

Please provide details of your Workers Compensation Policy.

Policy renewal date

 

 

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