Sch 2Forms

Schedule 2—Forms Form 2—Application for expedited decision South Australian Employment Tribunal Applicant [Tick 1 box] ☐ Worker ☐ Employer Worker's details Please complete all relevant parts of this section. Given name: Family name: Date of birth: Occupation: Fax: Employer's details Please complete all relevant parts of this section. Fax: Case manager's details If the employer is self-insured, leave this section blank. Fax: Representative's details If you have representation (eg legal, union or employer association), please complete all relevant parts of this section. Internal reference: Fax: Claim details Please complete all parts of this section. Describe the claim. If insufficient space, attach a separate page. Please attach any information (such as your claim form or medical reports) that may be relevant. Please provide a list of all attachments. Date of injury: Description of injury: Date of claim: Claim number (if known): What is the outcome you are looking for? Why do you think there has been an undue delay? [explain the reasons] Interpreter If you require an interpreter, please complete this section. Do you need an interpreter? ☐ Yes ☐ No If Yes, what language? Signature Signature of applicant or representative: Name: Date: Schedule 3—Self‑insured employers terms and conditions of registration 1 The employer must ensure that forms for making a claim under the Act, in a form approved by the Corporation, are reasonably available to the employer's workers. 2 The employer must ensure that all claims under the Act are promptly and efficiently investigated and determined. 3 The employer must ensure that any benefit to which a worker is entitled under the Act is— (a) provided promptly; and (b) periodically reviewed in accordance with the Act. 4 The employer must ensure, so far as is reasonably practicable, that up to date programs that are designed to prevent or reduce the incidence of work injuries are established and maintained at places where the employer's workers work. 5 (1) The employer must, in respect of each reporting period, provide the following information to the Corporation: (a) Employer details: (i) the Employer Registration Number; (ii) the relevant Location Number; (iii) the relevant Location Address; (b) Particulars relating to each new claim received by the employer during the reporting period: (i) the claim number assigned by the employer; (ii) the full name of the worker; (iii) the sex of the worker; (iv) the date of birth of the worker; (v) the language usually spoken at home by the worker; (vi) the worker's country of birth; (vii) the postcode of the worker's residence; (viii) the worker's notional weekly earnings (if applicable); (ix) the postcode of the location where the injury occurred; (x) if the injury occurred at a particular workplace—the predominant class of industry at that workplace; (xi) whether the worker is employed on a full time or part time basis by the employer; (xii) whether the worker is employed on a permanent or casual basis by the employer; (xiii) the occupation of the worker at the time of the injury (including, if the worker is an apprentice, making specific reference to that fact); (xiv) the main tasks usually performed by the worker in the stated occupation; (xv) the normal hours, and days per week, worked by the worker; (xvi) the date on which the worker commenced employment with the employer; (xvii) the activity being undertaken by the worker at the time of the occurrence of the injury; (xviii) the date of the occurrence of the injury; (xix) the time of day at which the injury occurred (so far as is known to the employer); (xx) the date on which the employer was first notified of the injury; (xxi) the apparent cause of the injury; (xxii) a description of the injury; (xxiii) a statement as to the parts of the worker's body affected by the injury; (xxiv) the date on which the worker ceased work (if incapacitated for work); (xxv) if relevant, the date of death of the worker; (xxvi) the date on which the occurrence of the injury, or the incident that caused the injury, was reported to the administrative unit of the Public Service that is, under a Minister, responsible for the administration of the Work Health and Safety Act 2012 (if applicable); (c) Particulars relating to each claim that is open during any part of the reporting period: (i) the RTWSA reference number; (ii) sufficient details to allow the worker and the claim to be identified; (iii) whether the claim has a serious injury classification; (iv) whether the claim comes under the National Injury Insurance Scheme; (v) the status of the claim (eg accepted, rejected, undetermined, finalised, reopened); (vi) whether a common law action has commenced in relation to the claim; (vii) the total time lost from work by the worker during the relevant period (if any); (viii) the worker's last known work status; (ix) the date on which the worker resumed work (if known); (x) the date on which the claim was determined and the date and effect of any redetermination of the claim; (d) Particulars relating to each claim on which action has occurred during the period, including details of any changes and, if relevant, the latest totals of payments in the following categories: (i) income maintenance; (ii) medical services (eg medical practitioner or dentist); (iii) medical—allied health; (iv) medical—other goods and services; (v) hospital outpatient; (vi) hospital inpatient; (vii) rehabilitation; (viii) lump sum payments (section 56 of the Act); (ix) lump sum payments (section 58 of the Act); (x) redemption of income maintenance payments (section 53 of the Act); (xi) redemption of medical expenses (section 54 of the Act); (xii) common law; (xiii) legal; (xiv) investigation; (xv) travel; (xvi) other goods and services; (xvii) other non‑compensation; (xviii) property damage; (xix) third party recovery; (e) Other information reasonably required by the Corporation (including information required to meet national data collection requirements). (2) For the purposes of subclause (1)— (a) the information must be provided in a manner and form (including by electronic means), and at a time, determined by the Corporation; and (b) the Corporation may, from time to time— (i) by notice in writing, waive or postpone the obligation to comply with the requirements of that subclause, either for an individual self‑insured employer or for self‑insured employers of a specified class, subject to conditions (if any) determined by the Corporation; and (ii) on giving reasonable notice (by further notice in writing), vary or revoke the operation of a notice under subparagraph (i), or vary, revoke or substitute a condition that applies under that subparagraph. (3) In this clause— reporting period means a period of 14 days or such longer period approved by the Corporation with respect to the relevant employer from time to time. 6 (1) The employer must deliver to the Corporation— (a) an audited copy of the employer's financial statements in respect of each financial year of the employer within 5 months after the end of the financial year; and (b) an actuarial report on the outstanding liabilities of the employer under the Act, as at the end of each financial year of the employer within 3 months after the end of the financial year. (2) For the purposes of this clause, the financial years of an employer are successive periods, not exceeding 12 months, determined by the employer to be the employer's financial years or, in the absence of such a determination, each period of 12 months ending on the 30th day of June. (3) The Corporation may require an actuary that provides a report under subclause (1) to have experience as an actuary that is at least equal to a standard set by the Corporation for the purposes of this provision. 7 (1) The employer must at all reasonable times allow an authorised officer to examine— (a) the accounting and other records of the employer; and (b) any system or facility used by the employer in connection with acting as a self‑insured employer under the Act. (2) The employer must provide such assistance as may be reasonably required to facilitate an examination referred to in subclause (1). (3) The employer must, at the request of a person carrying out an examination referred to in subclause (1), provide any explanations, information or assistance that the person may reasonably require for the purposes of the examination. (4) The employer must comply with any written notice served on the employer by an authorised officer requiring the employer to exercise or perform a power or function of the employer under the Act in accordance with the Act. 8 (1) The employer must ensure that there is in force at all times a guarantee given by a financial institution to or in favour of the Corporation which— (a) guarantees the payment of an amount to the Corporation in the event that the employer becomes insolvent or ceases to be a self‑insured employer; and (b) complies with subclause (3). (2) The amount guaranteed by a guarantee entered into for the purposes of subclause (1)— (a) must be an amount, at least equal to the prescribed sum, determined by the Corporation to be reasonable for the purposes of this provision after taking into account the principle that a scaling factor of 1.5 should be applied to— (i) an actuarial estimate of the value of the current and contingent liabilities of the employer under the Act at the time of the determination (whether or not claims have been made with respect to those injuries); plus (ii) an actuarial estimate of the value of the liabilities of the employer as a self‑insured employer under the Act in respect of work injuries attributable to traumas expected to arise from employment by the employer over the ensuing period of 12 months; less (iii) an actuarial estimate of the amounts expected to be paid out by the employer under the Act over the ensuing period of 12 months; and (b) must be reviewed annually. (3) A guarantee complies with this subclause if— (a) the guarantee is given by a financial institution which has a credit rating at least equal to a standard set by the Corporation for the purposes of this provision and which is specifically approved by the Corporation as a financial institution which can give guarantees under this clause; and (b) the guarantee is in a form, and for a term, approved by the Corporation. (4) A financial institution cannot give a guarantee under subclause (1) if the financial institution and the employer are related bodies corporate. (5) The Corporation and an employer may agree to enter into and maintain an arrangement that will apply in substitution for a guarantee under this clause if the Corporation is satisfied that the arrangement provides adequate and appropriate security to the Corporation in case the employer becomes insolvent or ceases to be a self‑insured employer and, in the event of such an agreement, the employer is not (while the agreement remains in force) required to comply with a preceding subclause. (6) In this clause— financial institution means— (a) an ADI; or (b) a person whose sole or principal business is the provision of financial services; prescribed sum means— (a) in respect of an amount that is to apply to a period that corresponds to, or ends during, 2015—$830 000; (b) in respect of an amount that is to apply to a period that corresponds to, or ends during, a subsequent year—a sum (calculated to the nearest multiple of $10 000) that bears to $830 000 the same proportion as the Consumer Price Index for the September quarter of the immediately preceding financial year bears to the Consumer Price Index for the September quarter, 2014; related bodies corporate has the same meaning as in section 129(15) of the Act. 9 The employer must ensure that there is in force at all times a contract of insurance, in a form approved by the Corporation, for an amount approved by the Corporation, in excess of an amount approved by the Corporation, against any liability of the employer that may arise under the Act as a result of the occurrence of 1 event or series of events during the period of the contract. 10 In relation to an employer that is a company incorporated, or taken to be incorporated, under the Corporations Act 2001 of the Commonwealth— (a) the employer must immediately give the Corporation written notice of the commencement of any procedure to liquidate or wind up the employer; and (b) the employer must, within 5 business days, give the Corporation written notice of— (i) the commencement of steps to merge or take over the employer or the undertaking of the employer; or (ii) a change in the board of directors of the employer that substantially changes the management of the employer; or (iii) a relocation of the undertaking of the employer; or (iv) the purchase or sale of any asset that materially changes the financial position of the employer, the composition of its workforce or the nature of the work undertaken by its workers; or (v) any other action that significantly affects the employer's ability to meet its liabilities under the Act.