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. Name * Date of application * Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year ABN * Please provide details of your Workers Compensation Policy. Workers compensation policy number Policy renewal date Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year Agent (Insurer) with whom you hold the policy Your principle business activity Should you wish to discuss your application further, call WorkCover NSW on 13 10 50.