S175C Private ruling form

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 Month Year

ABN *

Please provide details of your Workers Compensation Policy.

Workers compensation policy number

Policy renewal date

Day Month 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 74 72.