NSW QUAD BIKE SAFETY IMPROVEMENT PROGRAM REBATE APPLICATION FORM

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1 Proudly supported by NSW QUAD BIKE SAFETY IMPROVEMENT PROGRAM REBATE APPLICATION FORM APRIL 2017 SECTION 1. BUSINESS AND PAYMENT DETAILS I am a: Business owner Worker Suburb I have applied for a Quad Bike Safety Rebate previously State Postcode Business owner/worker name If you are a worker, written proof of approval from your employer to access this rebate must be attached to the application. Trading name Daytime contact number Mobile number Business name Number of full-time equivalent workers ABN REGISTERED BUSINESS ADDRESS Unit number/street number/property number (include Lot or DP number if applicable) Street name Suburb SECTION 1.1 BUSINESS DETAILS Is farming your/your employer s main business activity? How long has the business been operating? 0 5 years 6 10 years More than 10 years Does the employer own a quad bike or SSV that is used when conducting a business? Please provide details of the current quad bike/ssv that you own in the box below: Vehicle make State Postcode Vehicle model POSTAL ADDRESS Unit number/street number/property number (include Lot or DP number if applicable) Vehicle Identification Number (VIN) Street name Have you attended a relevant, educative interaction with SafeWork NSW prior to the purchase of the eligible safety solution(s)? Section 1.1 continued over 1/5

2 Which eligible educative interaction did you attend? Farm Safety Day Field Day Special Event Safety Advisory Visit Webinar OPERATOR PROTECTIVE DEVICE (QUADBAR OR ATV LIFEGUARD) Purchased? Name of event Date of attendance (DD/MM/YYYY) BANK ACCOUNT DETAILS Account name If you have purchased an OPD do you consent to your contact details (such as name, contact number) being provided to the University of New South Wales Transport and Road Safety (UNSW TARS) who is conducting the epidemiological study into their safety benefits to discuss your potential participation in the study? BSB Account number Did you fit the OPD to your existing quad bike in accordance with the manufacturers instructions? SECTION 1.2 CLAIM DETAILS HELMET Purchased? SIDE BY SIDE VEHICLES Purchased? SECTION 2. FURTHER HELP Where did you hear about these rebates? Farm Safety Day Field Day SafeWork NSW website Newspaper Country Women s Association website Alive and Well website Newsletter Radio Local Land Services TV Facebook Instagram Twitter NSW Department of Primary Industries Other Are you a member of? Membership number If you are not a member of, would you like to hear more about how to become a member? 2/5

3 SECTION 3. CHECKLIST To ensure your application can progress as quickly as possible, please take the time to check you have completed the following tasks. Have you: Included evidence of eligibility (for example ABN details)? Included vehicle specifications (make/model/vin)? Attended an eligible educative interaction with SafeWork NSW (prior to purchasing equipment) and included your registration form from the event? Attached your paid tax invoice for eligible safety solution(s) (after attending eligible educative interaction with SafeWork NSW)? Completed and signed the application form? SECTION 4. DECLARATION I declare that I have read and agree to the full terms and conditions I declare that I am: the owner of a business that is registered in NSW, is producing goods or providing services in NSW, falls within the scope of the NSW Work Health and Safety Act 2011, has 0 20 full-time workers (or equivalent), owns and uses a quad bike or SSV for the main purpose of the farming business and farming is your main source of income, or a worker employed by a person that meets the criteria identified in the above bullet point. I declare that I live in NSW I declare that I am not claiming this rebate on behalf of another business/individual. I confirm that I have attended an eligible educative interaction with SafeWork NSW prior to the purchase of eligible safety solutions for my business/myself and ABN as described above, and the safety solutions have been paid for, received, and fitted in accordance with manufacturer s instructions (if applicable) prior to my application date. I confirm that the safety solutions purchased are existing manufactured safety items that meet manufacturers guidelines, and all relevant standards. I declare that all information contained in this application is true and correct and is not false or misleading. I agree with the terms and conditions as outlined. I am aware that application processing times may vary and that the timelines provided are indicative only. Print name Signature Date (DD/MM/YYYY) Please send your completed form and applicable attachments to: qbsip@nswfarmers.org.au OR Quad Bike Safety Rebates PO Box 459 St Leonards NSW /5

4 TERMS AND CONDITIONS The following terms and conditions apply to the SafeWork NSW Quad Bike Safety Improvement Program Rebates Package (Program). Please read them carefully before applying. DEFINITIONS: Eligible educative interaction specific event operated or supported by SafeWork NSW including a Farm Safety Day, Agricultural Field Day, webinar and Safety Advisory Visit conducted by SafeWork NSW Officers. These interactions typically involve discussions with SafeWork NSW staff on quad bike safety relevant to your business. Eligible safety solutions existing manufactured safety items that meet all relevant standards, approvals, and legislative requirements and which are available for purchase by small businesses at commercial outlets for example competitive existing commercial products. Side by side vehicle (SSV) a side by side vehicle (SSV) for the purpose of this program is one designed for use in an agricultural environment, and fitted as standard with operator protective devices including a roll bar and three point seat belt/belts. The program excludes SSVs that are designed for recreation/sport and children. Operator Protective Device (OPD) there are currently only two OPDs that meet the criteria for this rebate. They are the Quadbar and the ATV Lifeguard. APPLICATION FOR THE SAFEWORK NSW QUAD BIKE SAFETY IMPROVEMENT PROGRAM REBATES PACKAGE 1.1 To be eligible to apply, you must fulfil the following criteria: Be an owner of a business that is registered in NSW, is producing goods or providing services in NSW, falls within the scope of the NSW Work Health and Safety Act 2011, has 0-20 full-time workers (or equivalent), owns and uses a quad bike or SSV for the main purpose of the farming business and farming is your main source of income or be a worker for a business owner that meets these criteria. The business owner must reside in NSW. You are not able to apply for a rebate in relation to a business registered in a state or territory other than NSW, or an investment trust, managed fund, strata title scheme, subsidiary of a larger business, or a voluntary association. Contact NSW Farmers Association on if you are unsure if your business is eligible Attend an eligible educative interaction with SafeWork NSW. Applicants must attend an eligible educative interaction prior to the purchase of any eligible safety solution. An eligible educative interaction includes attendance at an eligible safety event operated by SafeWork NSW such as (i) Farm Safety Day, (ii) Agricultural Field Day, (iii) webinar and/ or (iv) engaging in a Safety Advisory Visit with SafeWork NSW staff to discuss quad bike safety relevant to your business Purchase an eligible safety solution(s) after 19 July Complete and sign an application form agreeing to the terms and conditions of the rebate program Send a copy of your paid tax invoice(s), receipt(s) or proof of purchase, and other required documentation with a completed application form to the NSW Farmers Association. Eligible safety solutions need to be purchased from a registered business. All tax invoices and receipts must state the business/contractor s name, address, ABN/ ACN/BRN number, payment date, description and cost of solution Applications must be submitted within 4 months of the applicant attending an eligible educative interaction SafeWork NSW may cancel the program at any time for any reason, and without notice, including if funding for the program is exhausted. see further clause 7.1 below. ELIGIBILITY FOR A REBATE 2.1. Eligible rebate solutions must be existing manufactured safety items that meet all relevant standards, approvals, and legislative requirements and are available for purchase by small businesses at commercial outlets eg competitive existing commercial products. Rebates will not cover the design or manufacturing of new items, owner-built items, items that you have designed and manufactured to your specifications, purchase of raw materials, purchase of second-hand items, service repairs or maintenance. Rebates will not subsidise retrospective improvements made before the eligible educative interaction with SafeWork NSW or purchased before 19 July Rebate solutions do not cover products or equipment for domestic, recreational or social activities and must be for use on-farm in NSW The rebate is not available for goods or services that have already received a rebate from another SafeWork NSW safety initiative or rebate. r is it applicable to government agencies, or for businesses claiming on behalf of another business eg agents or consultants lodging applications on behalf of their clients. CLAIMING FOR A REBATE 3.1. Applicants are eligible for up to two rebates of up to $1,000 each. Each rebate may be for a combination of up to $1,000 per SSV, up to $500 per OPD and up to $90 per helmet. A rebate may be obtained for a maximum of one helmet per worker Business owners who applied for the rebate prior to 9 March 2017 will only be able to apply for one additional rebate Applying for the Quad Bike Safety Improvement Program Rebate does not preclude an applicant from applying for other rebate programs offered by SafeWork NSW if and when they become available, provided the applicant meets the Terms and Conditions of any other rebate program Items listed under Excluded items in the application form, including GST, freight and insurance costs, do not qualify for the rebate. CONFLICT OF INTEREST 4.1. You will not be eligible to obtain a rebate in relation to eligible safety solution(s) if you or a relative are (a) the supplier of the eligible safety solution; (b) employed by the supplier of the eligible safety solution; or (c) have any legal interest in the supplier of the eligible safety solution SafeWork NSW workers and contractors are not eligible to apply for a rebate during any period in which they are employed by SafeWork NSW or are providing services to SafeWork NSW. REFUND OF A REBATE 5.1. At any time (including after providing a rebate), SafeWork NSW may request information from applicants to verify that the eligible safety solution is effective and durable. If SafeWork NSW is not satisfied that the eligible safety solution is effective and durable, or if SafeWork NSW suspects that any part of the eligible safety solution has been on-sold by a business, SafeWork NSW may require an applicant to repay any rebate provided by SafeWork NSW. 4/5

5 5.2. Applicants may be required to repay the rebate if any of these terms and conditions are found to have been breached. FEEDBACK AND PUBLICITY 6.1. SafeWork NSW may contact participants for feedback on the Quad Bike Rebate Program and may publicise their business involvement in the Program with their prior approval in accordance with the Privacy and Personal Information Protection Act PROGRAM CHANGES 7.1 SafeWork NSW reserves the right to exercise its discretion to change any or all of the terms and conditions of the Program or to cancel the Program at any time. LIABILITY 8.1. The applicant acknowledges and agrees that as far as the law permits, SafeWork NSW (and its successors) and NSW Farmers accept no liability in respect to any claim, cause of action or loss or damage arising out of, or in relation to, training or goods/services that are the subject of this funding assistance The applicant agrees that they release SafeWork NSW and NSW Farmers from any claim or liability arising out of, or in relation to, the rebate that is the subject of the registration or rebate application, to the extent that claim or liability is not caused by SafeWork NSW or NSW Farmers negligence or breach of this application or any other term implied by law. PRIVACY NOTICE 9.1. SafeWork NSW and NSW Farmers collect and manages the personal information you provide in accordance with the Privacy and Personal Information Protection Act SafeWork NSW and NSW Farmers collect and use this information to determine whether your application is eligible for a rebate, to provide our services to you (such as to deliver safety programs, conduct follow-up surveys or inspections, invite you to participate in future research projects relating to quad bike safety), to improve the quality of our services, and to provide you with information about other services we offer. Your personal information may be provided to NSW Government agencies for the purpose of ensuring that the total of government benefits you receive does not exceed the total cost of your installed safety solution. Failure to provide the information requested in the application form may result in us not being able to process your application You have the right to access and correct any of your personal information at any time, once we have collected it. To access or amend your personal information relating to your rebate application, applications should be made in writing to the Privacy Contact Officer, SafeWork NSW Head Office, Locked Bag 2906, Lisarow, NSW Further information on our privacy policy is available at Catalogue. SW08282 Copyright SafeWork NSW 0417 SafeWork NSW, Donnison Street, Gosford, NSW 2250 Locked Bag 2906, Lisarow, NSW 2252 Customer Experience Website 5/5