EMPLOYER RETURN Of EARNINGS COIDA - Section 82

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EMPLOYER RETURN of EARNINGSCOIDA - Section 82Employers must submit to FEM a Return of Earnings form, certified as correct, by no later than 31 Marcheach year. The Return of Earnings statement must reflect the total amount of earnings (up to the maximum)paid by the employer to its employees during the period with effect from 01 March of the immediate precedingyear up to and including the last day of February of the following year.1. Herewith the revised ERoE form.2. Please complete and return to our office before 31 March.3. Please read the "Important Information and Guidelines" before completing thisform.4. The failure to submit a Return of Earning in the prescribed time and thesubsequent non-payment of the assessed premium by 30 June could resultin cancellation of any Merit Rebate DueThe following forms are attached for completion and information. Please return the completedforms - Schedules 1 to 4 (a) - to FEM before 31 March.Schedule 1I. Audit Confirmation requestSchedule 2II. Broad Based BEE Ownership Verification RequirementsSchedule 3III. Changes to the Employer details and General InformationSchedule 4IV. Employer's Return of EarningsSchedule 4 (a)V. Employer's Return of Earnings / Notes and CertificationSchedule 5 and 5 (a)VI. Important Information and GuidelinesNOTE: FEM is in the early investigation stages of various options in respect of new products. Possiblenew products we are investigating include: A separate top-up product to cater for the gap in benefits between the wage ceiling and theactual wage. Separate cover on the same basis as COID for local and foreign workers that are not currentlycovered under COIDShould you have any suggestions for other related products, please do not hesitate to call your localFEM officeNOTE:If you require assistance in this regard please contact FEM Underwriting Office.Kindly forward the completed return to the contact below.RA'EESAH ABED(011) 359 4320 [email protected] Fax To Email (011) 359 4395

Schedule No : 1AUDIT CONFIRMATIONDate :Policy Name :Policy No :FEM operates in terms of the Compensation for Occupational Injuries and Diseases Act (COIDA) and avery strict licence from the Department of Labour. We are governed by the Act and our licence, wetherefore have to abide by the terms and conditions at all times.As part of FEM's internal audit requirements, we have been requested to obtain confirmation of the figuressubmitted on the Employer's Return of Earnings forms subject to relevant maximum wage andconfirmation of the Nature of Business.1. Actual Earnings confirmation to be attached to the Employer Return of Earnings form.Please attach a letter (on the relevant letterhead ) from your Auditors or Accountant (whicheveris applicable) confirming the Actual Earnings for the period.2. Please confirm the Nature of Business.The Nature of Business is now a field on the EmployerReturn of Earnings and we will not be able to proceed with the assessment until this field iscompleted.Please note that failure to attach the above information could result in a delayed assessment andcould result in the forfeiture of any Merit Rebate due.NOTE:If you require assistance in this regard please contact FEM Underwriting Office.Kindly forward the completed return to the contact below.RA'EESAH ABED(011) 359 4320 [email protected] Fax To Email (011) 359 4395

Schedule No : 2BROAD BASED BEE OWNERSHIP VERIFICATIONDate:Policy Name :Policy No :Broad Based BEE Ownership Verification Requirements for THE FEDERATED EMPLOYERSMUTUAL ASSURANCE COMPANY (RF) PTY LTDAs our policyholder, we require your assistance in attaining as favourable and accurate a BB BEE scoreas possible.Part of the verification will require the ownership information of FEM's policyholders.Please provide us with your current verified BB BEE accreditation certificate, or the followinginformation (on a letterhead):1. The percentage of black ownership in the company2. The percentage of black women in the company3. The percentage held by Designated peopleThis information will be used to calculate FEM's BEE ownership score.Please return this information with your Employer Return of Earnings form.* Please ignore if submitted in the past 3 months.NOTE:If you require assistance in this regard please contact FEM Underwriting Office.Kindly forward the completed return to the contact below.RA'EESAH ABED(011) 359 4320 [email protected] Fax To Email (011) 359 4395

Schedule No : 3CHANGE of COMPANY CONTACT DETAILS / GENERAL INFORMATONPolicy Name :Policy No :Date:Part 1: EMPLOYER PARTICULARS1.1 Name of Employer1.2 Type of businessCC-PTYLTDClose Corporation Propietary LimitedPTNPartnershipJVTRJoint venture TrustSPOtherSole proprietor1.3 Company / CC1.4 Postal Address1.5 Directors (Names, ID Numbers and Inception Date)Attach a separate page if necessary1.6 Physical address1.7 Underwriting contact personNameTelephone No.Fax numberCell numberE-mail address1.8 Claims contact personNameTelephone No.Fax numberCell numberE-mail address(Mandatory)1.9 Nature of Business1.10 Allocation Split Note:1. Only allowed if employees exceed 1002. Maximum split of 2 classes3. Minimum 20 % per class4. Total % of splits to equal 100%Previous yearactualsCivil EngineeringGeneral Building over 12.2metres highGeneral Building under12.2 metres highCurrent yearestimatesPrevious yearactualsCurrent yearestimatesPlumbingErection of steelstructuresOther (Specify)1.11 Particulars of bank account:1.12 Member of: (circle) SAFCEC / MBA / ECA / NHBRC/ OTHER (Please specify)1.13 BBBEE COMPLIANT: yes (Please attach certificate) / no / exempt (Please attach a letter from yourauditors)

Schedule No : 4EMPLOYER RETURN of EARNINGSPolicy Name :Policy No :Date:Please refer to Information and Guidelines (Schedule 5) before completing this sectionPART 2 Please declare Earnings of All: Permanent,Temporary and Casual employees / Employees ofunregistered Sub-contractors / Employees working outside the Republic of South Africa.If Sub-Contractors are included attach a separate page if required

Schedule No : 4EMPLOYER RETURN of EARNINGSPolicy Name :Policy No :Date:NOTES IN RESPECT OF SCHEDULE 4 / CERTIFICATION of DECLARATION1. Calculation of Actual Earnings The Maximum wage for the period 1 March to end February the following year is calculated If Earnings are below the Maximum:Declare actual earning for each employee If Earnings are above the Maximum:Declare the Maximum (as stipulated) for each employee2. Calculation of Estimated Earnings The Maximum wage for the period 1 March to end February the following year is calculated If Earnings are below the Maximum:Declare actual earning for each employee If Earnings are above the Maximum:Declare the Maximum (as stipulated) for each employee3. To determine the average number of employees for one month - add the number of employees (asdefined on schedule 5) employed for each of the twelve months and divide the total by 12 (rounded upor down)4. Please provide a reason if the Number of Employees and / or the Total Earnings paid decreases /increases by more than 25 % in comparison to the previous period.ActualsEstimatesNOTEThe failure to submit a Return of Earnings in the prescribed time could result in the cancellation of any MeritRebate due.I hereby CERTIFY that the particulars as declared on Schedules 3 and 4 are true and correct.NamePositionSIGNATUREDate / /5. Please help us to improve our service by rating your service experience for the past year.PoorLess than satisfactory Meets expectationsGoodExcellent6. Feel free to leave any additional comments

Schedule No : 5IMPORTANT INFORMATION and GUIDELINESPolicy Name :Policy No :Date:NOTE The failure to submit a Return of Earnings in the prescribed time and the subsequent nonpayment of the assessed premium by 30 June could result in the cancellation of any MeritRebate due.1.1 EMPLOYEES"Employee" means a person who has entered into, or works under a contract of service or apprenticeshipor learnership with an employer, whether the contract is expressed or implied, oral or in writing andincludes :1. Any person in your employ (irrespective of earnings) including:a. All working directors of a company or Members of a Close Corporation.b. Site personnel including casual labour.c. All clerical / Administration staff.Irrespective of age, race, gender, whether employed permanently or temporarily and whether thewages / salaries are calculated to time worked or work done.2. The employees of a (Sub) Contractor / employer without proven Compensation cover are deemed tobe the employees of the (Mandator) Main Contractor and all their earnings must be included in Part 2of Schedule 4.3. A person provided by a Labour Broker, against payment to the Labour Broker for the rendering of aservice or performance of work and for which work or service such person is paid by the LabourBroker, is an employee of the Labour Broker. The earnings of such persons should not be included inyour Employer Return of Earnings.1.2 EARNINGSEarnings are all payments made regularly, before any deductions, whether in money or in kind toemployees.INCLUDED in the Gross Earnings are:1.2.3.4.5.6.7.Overtime that is of a regular nature.Bonuses of a regular nature e.g. (Annual Bonus).Commission of a regular nature.The cash value of food and quarters provided to employees as part of their remuneration package.Cash value of fringe benefits - company car, accommodation, reduced rates etc.Where the employee is remunerated in accordance with a package of benefits.Earnings / Drawings paid to working Directors of a Company or Members of a Close Corporation.NOTE:If you require assistance in this regard please contact FEM Underwriting Office.Kindly forward the completed return to the contact below.RA'EESAH ABED(011) 359 4320 [email protected] Fax To Email (011) 359 4395

Schedule No : 5 (a)IMPORTANT INFORMATION and GUIDELINESPolicy Name :Policy No :Date:EXCLUDED from the Gross Earnings are:1. Payments of a reimbursive nature.2. Occasional Overtime.3. Ex-Gratia payments.4. Intangible fringe benefits such as the taxable portion of employer contributions to medical aid /pension etc.5. Payments to cover special expenses such as subsistence and travel costs, lunches etc.6. Travel and other occasional allowance.7. If a Director / Member's only remuneration is profit sharing, the Director / Member is not an employeein terms of COID Act.A sole Proprietor or partners in a Partnership are not regarded as "employees" in terms of the COID Actand their earnings should therefore not be declared in the Employer Return of Earnings form.1.3 FINAL EARNINGSIf you have ceased trading, please include the date of cessation and declare the final earnings paid to thatdate.1.4 MINIMUM ASSESSMENTIn terms of Section 83.2 (b) of the COID Act, FEM has a minimum premium of R5, 000.00.1.5 LETTER of GOOD STANDINGPlease note that in terms of the OHS and COID Acts a Letter of Good Standing may only be issued byFEM provided : The latest Employer Return of Earnings has been received by FEM. Any outstanding premium has been paid in full.Letters of Good Standing are not issued automatically and will only be issued upon request.The Federated Employers Mutual Assurance Company (RF) Proprietary Limited shall at their owndiscretion institute criminal proceedings against perpetrators who unlawfully alter or deface this letter withintent to defraud or misinterpret facts contained herein.NOTE:If you require assistance in this regard please contact FEM Underwriting Office.Kindly forward the completed return to the contact below.RA'EESAH ABED(011) 359 4320 [email protected] Fax To Email (011) 359 4395