Part Form 1—Licence application - Safety, Rehabilitation and Compensation Regulations 2002 - Form 1—Licence application

Form 1—Licence applicationForm 1—Licence application

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Form 1—Licence application

Safety, Rehabilitation and Compensation Act 1988

Safety, Rehabilitation and Compensation Commission

APPLICATION FOR GRANT OF LICENCE

To: The Safety, Rehabilitation and Compensation Commission

GPO Box 9905

CANBERRA ACT 2601

I, …………………………………………………………………………………

(principal officer)

of …………………………………….…………...………………(the applicant)

(name of applicant)

apply to the Safety, Rehabilitation and Compensation Commission (the Commission) for the grant of a licence to the applicant under section 102 of the Safety, Rehabilitation and Compensation Act 1988 (the Act).

SCOPE OF LICENCE

The applicant applies for a licence with the following scope:

(delete whichever is not applicable)

(a) a licence to accept liability to pay compensation and other amounts under the Act in respect of particular injury, loss or damage suffered by, or in respect of the death of, some or all employees; AND/OR (b) a licence authorising the licensee to manage some or all of the claims by employees of the licensee.

Note: An eligible corporation must apply to the Commission for a licence with scope for both acceptance of liability and acceptance of the management of claims—see subsection 98A(3) of the Act.

The applicant applies for a licence to apply to:

(delete whichever is not applicable)

(a) some of its employees; OR (b) all of its employees.

PARTICULARS AND INFORMATION

Insert here the particulars of the applicant and information to be contained in the application as prescribed by regulations 11 and 12 under paragraphs 102(1)(b) and (c) of the Act.

Note: The applicant must attach to this application the documents prescribed by regulations under paragraph 102(1)(c) of the Act.

The applicant certifies that the particulars and information provided are correct and that any copies of documents provided are true copies of the originals of those documents.

UNDERTAKINGS

The applicant undertakes to pay to Comcare the application fee equal to the amount estimated by the Commission to be the cost of considering the application in accordance with subsection 102(2) of the Act.

If a licence is granted to the applicant, the applicant undertakes to:

comply with the requirements of the Act that apply to it; and
comply with any conditions laid down in the Act and any conditions that may be determined from time to time by the Commission; and

Item	Detail
1	The full name of the applicant
2	The business name (if any) used by the applicant, and the date and place of registration of such business name
3	The applicant’s ABN
4	The full street address and postal address of the applicant’s principal office, and of any other registered office
5	The name, telephone number and facsimile number of an officer nominated by the applicant for communication relating to the application
6	If the applicant is a Commonwealth authority—the name of the Act by which it is established
7	If the applicant is an eligible corporation:(a) the date and place of incorporation; and(b) the names and shareholdings of:(i) if there are more than 10 shareholders—each of the 10 principal shareholders; or(ii) if there are 10 shareholders or less—each shareholder
8	The names of the directors or members of the governing body (if any) of the applicant
9	An organisational chart setting out:(a) the structure of the applicant; and(b) the subsidiaries (if any) of the applicant
10	The total number of employees, disaggregated by location and structure
11	The total salary and wage expenditure for the last financial year, disaggregated by location and structure