The Workers Compensation Exemption Form serves as a crucial legal instrument within New Zealand's accident compensation system. While New Zealand operates under a universal no-fault accident compensation scheme through ACC, there are specific circumstances where alternative arrangements may be necessary or preferred. This document is typically used when employees are working internationally, engaged in specialized industries, or covered by alternative comprehensive insurance schemes. The form must comply with the Accident Compensation Act 2001 and related legislation, requiring detailed information about the parties involved, the basis for exemption, and alternative compensation arrangements. It's essential for establishing clear legal parameters when deviating from the standard ACC coverage and protecting both employer and employee interests.
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1. Worker Details: Full legal name, contact information, and identification details of the worker seeking exemption
2. Employer Details: Full legal name, business registration number, and contact information of the employer
3. Work Arrangement: Description of the specific work arrangement, including role, duties, and employment status
4. Basis for Exemption: Clear statement of the grounds under which the exemption is being sought, with reference to relevant legislation
5. Acknowledgment of Effects: Explicit statement acknowledging understanding that this exemption may affect accident compensation coverage
6. Duration of Exemption: Specific timeframe for which the exemption is being sought or will be valid
7. Declaration: Formal declaration by both parties confirming the accuracy of information provided
1. Alternative Insurance Arrangements: Details of any private insurance or alternative compensation arrangements, required when the worker has separate coverage
2. Special Conditions: Any specific conditions or requirements attached to the exemption, used when there are particular circumstances to note
3. Overseas Work Details: Information about work conducted outside New Zealand, required for international work arrangements
4. Previous Claims History: Details of any previous ACC claims or workplace incidents, included when relevant to the exemption application
1. Schedule A - Risk Assessment: Detailed assessment of workplace risks and mitigation strategies relevant to the exemption
2. Schedule B - Supporting Documentation: List and copies of all required supporting documents (e.g., insurance certificates, medical certificates)
3. Appendix 1 - Relevant Legislative Excerpts: Key excerpts from relevant legislation supporting the exemption application
4. Appendix 2 - ACC Guidelines: Applicable ACC guidelines and policies relating to exemptions
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