This form is prepared for the purpose of section 175B of the Workers Compensation Act 1987, Part 5B section 31G-31J of the Pay-roll Tax Act 1971 and s127 and 127A of the Industrial Relations Act 1996.

If this form is completed in accordance with these provisions, a principal contractor is relieved of liability for workers compensation premiums, pay-roll tax and remuneration due or payable by the subcontractor.