Applications

ReturnToWorkSA will provide Retro Paid Loss (RPL) application packs automatically to current RPL participants.
For further information regarding RPL participation, please contact Emily Goldie or Emma Dicker.
Emily Goldie
Underwriter
08 8233 2300 I 0437 434 460

Emma Dicker
Underwriter
08 8233 2167 I 0437 617 969

Completed applications should be submitted electronically at .
Applications must include all the information required on the application form and the 2018-19 remuneration estimate.
Applications for the 2018-19 RPL arrangement close on 31 May 2018
2018-19Application form: Retro-Paid Loss arrangement
Return to Work Act 2014(the Act)
Return To Work Corporation of South Australia ABN 83 687 563 395
Employer Name: / Click to Enter Employer Name
Employer Number: / Click to Enter Employer Number /
Employer contact person (this must be an employee of the employer)
Name: / Click here to enter Name /
Position title: / Click here to enter position title / Telephone: / Click here to enter Telephone /
Mobile: / Click here to enter Mobile / Email: / Click here to enter Email /
Employer Group details
Are you a member of a group for payroll tax purposes? (The Act enables ReturnToWorkSA to group employers who are capable of being treated as a member of a group under the Payroll Tax Act 2009.) / ☐
Yes / ☐
No
Signing the application form confirms that the employer or group of employers:
  1. has read and understood the specified criteria for application contained in part 3 of the ‘Retro Paid Loss 2018-19 - Criteria, terms & conditions’ (“RPL Booklet”) and agrees to the terms and conditions contained in part 4 of the RPL booklet.
  2. has considered the implications of an RPL arrangement on their own premium costs and is aware that an RPL arrangement can result in a higher or lower premium cost overall, depending on an employer or group of employers’ injury prevention and management performance.
  3. consents to ReturnToWorkSA examining their workers compensation and Work Health and Safety compliance history as part of the process of verification of the employer or group of employers suitability for an RPL arrangement.
  4. understands that any significant change in remuneration during the premium period (in accordance with part 5 of the Provision of Remuneration Information Notice 2016 as a reduction or increase of more than 20%) must be advised to ReturnToWorkSA and will require a premium recalculation.
  5. understands that the premium will be recalculated on lodgement of a reconciliation statement (declaration of actual remuneration) or if a ReturnToWorkSA audit identifies a difference in declared remuneration.
  6. ifthe application is for a Trust, acknowledges that the trustees must promptly notify ReturnToWorkSA in writing when any of the details notified in this application or in the RPL booklet change. Trustees must also promptly notify ReturnToWorkSA when:
a)they cease to be trustees of the relevant trust (whether by choice or otherwise)
b)if they become a corporation, that they apply to take the benefit of any relief from bankruptcy or become an externally-administered body corporate (as defined in the Corporations Act 2001) or enters into (or proposes to enter into) an arrangement or composition with its creditors
c)new trustees are appointed or existing trustees are removed.
I confirm that I have read and understood the specified criteria for application, contained in part 3 of the RPL Booklet and that I agree to be bound by the terms and conditions contained in part 4 of theRPL Booklet. The person signing this application warrants that they have authority to bind the Employer to this arrangement.
Please check this box if you have read the above document. ☐
Signature of Chief Executive Officer or Board member
Print Name and title
Name and position title
NB: Please ensure that your 2018-19 estimated remuneration is provided with this application.