- with Bank Details -
Name of Employer
«MyCompanyLegalName»
Employer ABN
«MyCompanyVatRegNo»
Regarding
«FirstName» «MI» «LastName»
Date of Birth
«BirthDate»
Employment Status «EmploymentStatus»
Date of Commencement
«StartDate»
Hours Worked Per Week
«WeeklyHours»
Employed Under Name
«FirstName» «MI» «LastName»
Name of Business worked for
(if different from above)
Date Employment Ceased
(if applicable) «LeftDate»
Dates of employment
(where employment has not been continuous)
____ / ___ / ___ to ___ / ___ / ___
___ / ___ / ___ to ___ / ___ / ___
___ / ___ / ___ to ___ / ___ / ___
Workers’ Compensation Claim
(answer Yes or No)
Period of time Workers’ Compensation Paid For
Name of Workers’ Compensation Insurance Company
Net Pay paid into:
Bank Name «BankName»
Branch Code «BankCode»
Account Name «BankAccountName»
Account Number «BankAccountNumber»
Deduction paid into:
Bank Name «Bank2Name»
Branch Code «Bank2Code»
Account Name «Bank2AccountName»
Account Number «Bank2AccountNumber»
Deduction paid into:
Bank Name «Bank3Name»
Branch Code «Bank3Code»
Account Name «Bank3AccountName»
Account Number «Bank3AccountNumber»
Refer to the attached Statement of Payments showing the date and amount of
each wage payment to the person named above for the required period.
«Signature»
«Title»
«MyCompanyPhoneNumber»
«LetterDate»
If this form was completed by a business with fewer than 20 employees, please provide estimate of the time taken to complete it. Please include the actual time spent for each employee involved, in reading the instructions, obtaining the information and providing the answers.
Hours __________ Minutes ______________
