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 SIRA on 13 10 50.