Declaration of Actual Remuneration This field is hidden when viewing the formWork Request IDThis field is hidden when viewing the formLegal EntityWorkers Compensation and Injury Management Act 2023The Workers Compensation and Injury Management Act 2023 requires an employer as soon as practicable after the end of the policy period in their workers compensation policy to declare the total remuneration actually paid or payable to the employer’s workers over the previous policy period. To help you complete this form we have enclosed or attached a supporting document for your reference: Important Information. Please read Important Information as it includes information on terms used in this form, and refers to important requirements and publications issued under the Act that are relevant to making a declaration of actual total remuneration.1. Policy DetailsPolicy NumberWorkcover WA NumberFromPolicy Period (DD/MM/YYYY)ToPolicy Period (DD/MM/YYYY)2. Employer DetailsInsured Employer NameABN(Required)Postal Address Street Suburb State Post Code Business DescriptionPrimary Business LocationContact Email Contact Phone Number3. Actual Total RemunerationEnter the actual total remuneration in the sections below for each type of worker that you employed or engaged during the policy period. Refer to the WorkCover WA Remuneration Guidelines for the meaning given to ‘remuneration’ and what payment types are included and excluded.3.1 General EmployeesProvide the actual total remuneration paid or payable to your general workers/ employees including fulltime, part time and casual workers, and apprentices. Do not include working directors or contractors/ subcontractors as you will declare these types of workers separately on this form. * Refer to the WorkCover WA Industry Classification Order for premium rating classes and codes (PRCs) that apply to an employer’s business activities 1. PRC code of employer’s business activities*1. PRC class description of employer’s business activities*1. Total number of workers/employees1. Actual total remuneration ($)2. Add another PRC codeNoYes2. PRC code of employer’s business activities*2. PRC class description of employer’s business activities*2. Total number of workers/employees2. Actual total remuneration ($)3. Add another PRC codeNoYes3. PRC code of employer’s business activities*3. PRC class description of employer’s business activities*3. Total number of workers/employees3. Actual total remuneration ($)4. Add another PRC codeNoYes4. PRC code of employer’s business activities*4. PRC class description of employer’s business activities*4. Total number of workers/employees4. Actual total remuneration ($)5. Add another PRC codeNoYes5. PRC code of employer’s business activities*5. PRC class description of employer’s business activities*5. Total number of workers/employees5. Actual total remuneration ($)3.2 Working DirectorsProvide details of all working directors covered under the policy and the actual total remuneration paid to each working director listed. See Important Information for more information on working directors.1. Name of Working Director Full Name 1. Type of work performed1. Actual total remuneration ($)2. Add Another Director?NoYes2. Name of Working Director Full Name 2. Type of work performed2. Actual total remuneration ($)3. Add Another Director?NoYes3. Name of Working Director Full Name 3. Type of work performed3. Actual total remuneration ($)4. Add Another Director?NoYes4. Name of Working Director Full Name 4. Type of work performed4. Actual total remuneration ($)5. Add Another Director?NoYes5. Name of Working Director Full Name 5. Type of work performed5. Actual total remuneration ($)3.3 Contractors / SubcontractorsProvide the actual total remuneration paid or payable and/ or total contract value for contractors / subcontractors that are, or are deemed to be, your workers under the Act. See Important Information for more information on contractors / subcontractors.a. Labour OnlyNoYesa. Description of work performeda. Total number of workersa. Actual total remuneration (if known) ($)a. Total contract value ($)b. Labour & ToolsNoYesb. Description of work performedb. Total number of workersb. Actual total remuneration (if known) ($)b. Total contract value ($)c. Labour & PlantNoYesc. Description of work performedc. Total number of workersc. Actual total remuneration (if known) ($)c. Total contract value ($)d. Labour & MaterialsNoYesd. Description of work performedd. Total number of workersd. Actual total remuneration (if known) ($)d. Total contract value ($)e. Labour, Plant & MaterialsNoYese. Description of work performede. Total number of workerse. Actual total remuneration (if known) ($)e. Total contract value ($)Additional InformationPlease provide any additional information if it could not be included on the form above e.g. additional directors or PRC codes and their related details.Declaration by or on Behalf of an EmployerYou must complete the statement below to verify the information that you have provided in this form regardless of whether you are renewing your workers compensation policy or not.Name(Required) First Name Last Name Position(Required)Your business/entity(Required)Phone(Required)Email(Required) I confirm that the information provided in this declaration and any attachments are true, correct and complete and that no information has been suppressed or omitted.(Required) Yes I am authorised as the employer/ by the employer to complete and sign this declaration.(Required) Yes Penalties may apply for providing false, misleading or incomplete informationSignature(Required)Date(Required) MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. 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