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["Weekly Compensation Wage Reimbursement Form"]
["Employer Details"]
[]
[null,"Organisation Name",null,null,null,"Client Number",null,null,"Policy Number"]
[]
[null,"Cost Centre Name",null,null,null,"Address"]
[]
[]
["Payroll Officer/Claim Contact",null,null,null,null,"Email  Address"]
[]
["Name( Person that is completing this form if different than payroll officer)",null,null,null,null,null,null,null,"Date"]
[]
[null,"EFT Details (only if not already provided to CCI)"]
[null,"Account Name",null,null,null,"Payee Type"]
[]
[null,"BSB",null,"Account Number"]
[]
[null,"EFT Remittance Email Address",null,null,null,null,"EFT Reference/Invoice Number"]
[]
["Worker's Details"]
[]
[]
[null,null,null,"STATE","NSW","Name",null,null,"Claim Number"]
[]
["Pre-Injury Average Weekly Earnings (PIAWE)",null,null,null,null,"Pre Injury Determined Weely Hours (PID HOURS)"]
[]
["Weekly Compensation Wage Reimbursement Form must be completed in a 7 day weekly format. Exceptions to this rule apply when:\n• The first date of incapacity falls mid-week.\n• The income support cease or closed period end date falls mid-week."]
[]
["Weeks Paid","Entitlement Week",null,"Entitlement Period",null,null,"DWB (Auto)","Earnings","Hours Worked","Hours Lost \n(Auto)\n","Reimbursement\n(Auto)"]
[null,"From","To"]
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["Total Reimbursement",null,null,null,null,null,null,{"$f":"SUM(H31:H34)","v":0},{"$f":"SUM(I31:I34)","v":0},{"$f":"SUM(J31:J34)","v":0},{"$f":"SUM(K31:K34)","v":0}]
[]
["Appendix"]
[]
["•   Weeks Paid- Number of pay weeks (calculated on 7 day week) since date of injury\n•   Entitlement Week- Place the dates from and to for the period that is reflected on the payslip\n•   Entitlement Period- Select the applicable capacity in drop down option on the basis of period number of pay weeks since injury and worker's capacity for work\n•   Determined Weekly Benefit (DWB)(Auto calculated field)- The maximum weekly benefit entitlement amount for one week relating to the payment period. For more information, Please visit below workers compensation website for maximum weekly benefit entitlement.\n•   Earnings- The worker's earnings for actual work performed in the week including the first week and last week of claims benefit period\n•   Hours worked- applies to the actual work performed by the worker during the weekly pay cycle period.\n•   Hours Lost (Auto calculated field)- This is the total hours being claimed\n•   Reimbursement (Auto calculated field) -Enter the total claimable amount for the hrs lost during weekly pay cycle.\n•   Verify- Please click verify button below for mandatory fields before sending this form to us.\n•   Example- Company ABC seeking wage reimbursement for injured worker Mr X for the period 01/08/2021 to 28/08/21. Mr X has had 33 weeks entitlement paid since date of injury. Example shows Mr X worked             10 hr during the week period 08/08/21-14/08/21.\n\n\n\n"]
["NSW State-","https://www.sira.nsw.gov.au/claiming-compensation/workers-compensation-claims"]
["ACT State-","Workers compensation - WorkSafe ACT"]
["If you have any questions regarding completing this form than please contact us on 1300 110 442 or through email on workerscompensation@ccinsurance.org.au"]
[]
[]
[]
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[]
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[null,null,null,null,"YES",{"$f":"IF(#REF!=B138,'NAT1005 Lookup (2)'!B5*A35,'NAT1005 Lookup'!B5*A35)","v":{"$error":"#REF!"}},null,null,5,{"$f":"IF(#REF!=\"\",0,(#REF!-#REF!+1)/5)","v":{"$error":"#REF!"}}]
["Employer",{"$f":"C4","v":0},0,null,"NO",{"$f":"IF(#REF!=B138,'NAT1005 Lookup (2)'!C5*A35,'NAT1005 Lookup'!C5*A35)","v":{"$error":"#REF!"}},{"$f":"VLOOKUP(#REF!,E87:F88,2,FALSE)","v":{"$error":"#REF!"}},null,7,{"$f":"IF(#REF!=\"\",0,(#REF!-#REF!+1)/7)","v":{"$error":"#REF!"}}]
["Injured Worker",{"$f":"G23","v":0},{"$f":"G88","v":{"$error":"#REF!"}}]
["Cost Center",{"$f":"G4","v":0}]
[]
["EFT",null,null,"Max Rate",2254.6]
["CHEQUE",0.95,0.8,null,null,null,null,null,null,"Employer",{"$f":"C4","v":0}]
["NSW",{"$f":"E92/B93","v":2373.2600000000002},{"$f":"E92/C93","v":2818.25},null,null,null,null,null,null,"Cost Center",{"$f":"C6","v":0}]
["Select an Option"]
["WPP005 0-13 weeks (first entitlement period) = 95% PIAWE",{"$f":"E25*0.95","v":0},"WPP005"]
["WPP006 14-130 weeks (second entitlement period) \nworking 15 hours or more = 95% PIAWE",{"$f":"E25*0.95","v":0},"WPP007"]
["WPP007 14-130 weeks (second entitlement period) \nno capacity or working less than 15 hours = 80% PIAWE",{"$f":"E25*0.8","v":0},"WPP006"]
["WPP008 Weekly payments after 130 weeks = 80% PIAWE",{"$f":"E25*0.8","v":0},"WPP008"]
[]
["ACT"]
["WP1- Total Incapacity 0-26 Weeks = 100% PIAWE",{"$f":"E$25","v":0},"WP1"]
["WP2- Total Incapacity over 26 weeks = 65% PIAWE",{"$f":"E$25*0.65","v":0},"WP2",null,null,null,null,null,null,null,null," "]
["WP5- Partial Incapacity If working up to 25% Pre-incapacity hours  = 65% PIAWE",{"$f":"E$25*0.65","v":0},"WP4",null,null,null,null,null,null," WRS"]
["WP5- Partial Incapacity If working between 25% - 50% Pre-incapacity hours  = 75% PIAWE",{"$f":"E$25*0.75","v":0}]
["WP5- Partial Incapacity If working between 50% - 75% Pre-incapacity hours  = 85% PIAWE",{"$f":"E$25*0.85","v":0}]
["WP5- Partial Incapacity if working between 75% - 85% Pre-incapacity hours  = 95% PIAWE",{"$f":"E$25*0.95","v":0}]
["WP5- Partial Incapacity If working more than 85% of Pre-incapacity hours  = 100% PIAWE",{"$f":"E$25","v":0}]
[null,{"$f":"E$25","v":0},"WP5"]
["TAS"]
["Total incapacity 0-25 Weeks.",{"$f":"E$25","v":0},"WP1",null,null,null,null,null,null,{"$f":"J11","v":"00:00:00"}]
["Total incapacity 25-77 Weeks.",{"$f":"E$25*90%","v":0},"WP2"]
["Total incapacity Over 77 weeks.",{"$f":"E$25*80%","v":0},"WP3"]
["Partial Not Working.",{"$f":"E$25","v":0},"WP4"]
["Partial Working.",{"$f":"E$25","v":0},"WP5"]
["WA"]
["Total Incapacity",{"$f":"E$25","v":0},"WP1"]
["Partial Not Working,",{"$f":"E$25","v":0},"WP2"]
["Partial Working,",{"$f":"E$25","v":0},"WP3"]
["Interest",{"$f":"E$25","v":0},"WP8"]
["SA"]
["Total Incapacity-",{"$f":"E$25","v":0},"WTO"]
["Partial Not Working-",{"$f":"E$25","v":0},"WNW"]
["Partial Working-",{"$f":"E$25","v":0},"WWO"]
["Interest-",{"$f":"E$25","v":0},"WIN"]
["Back Pay/Make up Pay-",{"$f":"E$25","v":0},"WMU"]
["NT"]
["Total Incapacity:",{"$f":"E$25","v":0},"WTO"]
["Partial Not Working:",{"$f":"E$25","v":0},"WNW"]
["Partial Working:",{"$f":"E$25","v":0},"WWO"]
["Interest:",{"$f":"E$25","v":0},"WIN"]
["Back Pay/Make up Pay:",{"$f":"E$25","v":0},"WMU"]
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["Password (for Protected sheet)",null,"SuperAteam"]
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[]
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[0.65,"2020-2021"]
[0.75,"2019-2020"]
[0.85,"2020-06-30"]
[0.95]
[1]

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["SCALE 2",null,null,null,"SCALE 6",null,null,null,"SCALE 9",null,"Illness"]
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[]
[0,0,0,null,0,0,0,null,0,0,0]
[359,0.19,68.346199999999996,null,359,0.19,68.346199999999996,null,566,0.19,107.57689999999999]
[438,0.28999999999999998,112.1942,null,721,0.19900000000000001,74.836500000000001,null,627,0.315,185.99520000000001]
[548,0.21,68.346500000000006,null,739,0.249,111.8308,null,693,0.41499999999999998,255.33369999999999]
[721,0.219,74.8369,null,865,0.37769999999999998,223.20580000000001,null,721,0.42399999999999999,261.82400000000001]
[865,0.34770000000000001,186.21190000000001,null,924,0.3377,186.21190000000001,null,865,0.47270000000000001,303.86059999999998]
[1282,0.34499999999999997,182.75040000000001,null,1282,0.33500000000000002,182.75040000000001,null,941,0.34770000000000001,186.2115]
[2307,0.39,286.59649999999999,null,2307,0.38,286.59649999999999,null,1282,0.34499999999999997,182.75040000000001]
[3461,0.47,563.51959999999997,null,3461,0.46,563.51959999999997,null,2307,0.39,286.59649999999999]
[null,null,null,null,null,null,null,null,3461,0.47,563.51959999999997]
[null,null,null,null,null,null,null,null,"","",""]
[]
[]
["LOOKUP TABLES",null,null,null,null,null,null,null,"LOOKUP TABLES",null,null,null,"LOOKUP TABLES"]
["SCALE 3",null,null,null,null,null,null,null,"SCALE 10",null,"Couple",null,"SCALE Actors",null,"Actors"]
["$","a","b",null,null,null,null,null,"$","a","b",null,"$","a","b"]
[]
[0,0.32500000000000001,0.32500000000000001,null,null,null,null,null,0,0,0,null,0,0,0]
[2307,0.37,103.8462,null,null,null,null,null,521,0.19,99.153800000000004,null,449,0.152,68.346199999999996]
[3461,0.45,380.76920000000001,null,null,null,null,null,583,0.315,172.02879999999999,null,548,0.23200000000000001,112.1942]
["","","",null,null,null,null,null,693,0.41499999999999998,241.3673,null,685,0.16800000000000001,68.346500000000006]
[null,null,null,null,null,null,null,null,721,0.42399999999999999,247.85769999999999,null,901,0.17519999999999999,74.8369]
[null,null,null,null,null,null,null,null,829,0.29899999999999999,144.17500000000001,null,1081,0.2782,186.21190000000001]
[null,null,null,null,null,null,null,null,865,0.34770000000000001,186.2115,null,1602,0.27600000000000002,182.75040000000001]
[null,null,null,null,null,null,null,null,1282,0.34499999999999997,182.75040000000001,null,2884,0.312,286.59649999999999]
[null,null,null,null,null,null,null,null,2307,0.39,286.59649999999999,null,4326,0.376,563.51959999999997]
[null,null,null,null,null,null,null,null,3461,0.47,563.51959999999997,null,"","",""]
[null,null,null,null,null,null,null,null,"","",""]
[]
[]
[]
["ML Adjustment S2",null,null,null,null,"ML Adjustment S6"]
["Weekly earnings threshold",null,null,438,null,"Weekly earnings threshold",null,null,739]
["Weekly earnings shade-in threshold",null,null,548,null,"Weekly earnings shade-in threshold",null,null,924]
["Medicare levy family threshold",null,null,38474,null,"Medicare levy family threshold",null,null,38474]
["Weekly Family Threshold divisor",null,null,52,null,"Weekly Family Threshold divisor",null,null,52]
["Additional child",null,null,3533,null,"Additional child",null,null,3533]
["Shading Out Point multiplier",null,null,0.1,null,"Shading Out Point multiplier",null,null,0.05]
["Shading Out Point divisor",null,null,0.08,null,"Shading Out Point divisor",null,null,0.04]
["Weekly Levy Adjustment factor",null,null,438.48,null,"Weekly Levy Adjustment factor",null,null,739.88]
["Medicare levy",null,null,0.02,null,"Medicare levy",null,null,0.01]
[]
["Number of Children",null,"Threshold","Reduction",null,"Number of Children",null,"Threshold","Reduction"]
[0,null,924,739.88,null,0,null,924,739.88]
[1,null,1009,807.83,null,1,null,1009,807.83]
[2,null,1094,875.77,null,2,null,1094,875.77]
[3,null,1179,943.71,null,3,null,1179,943.71]
[4,null,1264,1011.65,null,4,null,1264,1011.65]
[5,null,1349,1079.5999999999999,null,5,null,1349,1079.5999999999999]
[6,null,1434,1147.54,null,6,null,1434,1147.54]
[7,null,1519,1215.48,null,7,null,1519,1215.48]
[8,null,1604,1283.42,null,8,null,1604,1283.42]
[9,null,1689,1351.37,null,9,null,1689,1351.37]
[10,null,1774,1419.31,null,10,null,1774,1419.31]
["Additional",null,85,67.940000000000055,null,"Additional",null,85,67.940000000000055]
[]
[]
[]
[]
[]
[]
[]
["SCALE HELP TFTR",null,null,null,"SCALE HELP NTFT",null,null,null,"SCALE FS TFTR",null,null,null,"SCALE FS NTFT"]
["$","a","b",null,"$","a","b",null,"$","a","b",null,"$","a","b"]
[]
[0,0,0,null,0,0,0,null,0,0,0,null,0,0,0]
[896,0.01,0,null,546,0.01,0,null,1110,0,0,null,760,0,0]
[1035,0.02,0,null,685,0.02,0,null,1363,0,0,null,1013,0,0]
[1097,2.5000000000000001E-2,0,null,747,2.5000000000000001E-2,0,null,1934,0,0,null,1584,0,0]
[1163,0.03,0,null,813,0.03,0]
[1232,3.5000000000000003E-2,0,null,882,3.5000000000000003E-2,0]
[1306,0.04,0,null,956,0.04,0]
[1385,4.4999999999999998E-2,0,null,1035,4.4999999999999998E-2,0]
[1468,0.05,0,null,1118,0.05,0]
[1556,5.5E-2,0,null,1206,5.5E-2,0]
[1649,0.06,0,null,1299,0.06,0]
[1748,6.5000000000000002E-2,0,null,1398,6.5000000000000002E-2,0]
[1853,7.0000000000000007E-2,0,null,1503,7.0000000000000007E-2,0]
[1965,7.4999999999999997E-2,0,null,1615,7.4999999999999997E-2,0]
[2082,0.08,0,null,1732,0.08,0]
[2205,8.5000000000000006E-2,0,null,1855,8.5000000000000006E-2,0]
[2340,0.09,0,null,1990,0.09,0]
[2480,9.5000000000000001E-2,0,null,2130,9.5000000000000001E-2,0]
[2629,0.1,0,null,2279,0.1,0]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["SCALE NTFN",null,null,null,"SCALE TFN"]
["$","a","b",null,"$","a","b"]
[]
["Resident",0.47,0,null,"Resident",0.13,0]
["Foreign resident",0.45,0,null,"Foreign resident",0.32500000000000001,0]
[]
[]
[]
[]
[]
[]
["WHM TABLE"]
["Income Range",null,"Tax Rate"]
[0,45000,0.15]
[45000,120000,0.32500000000000001]
[120000,180000,0.37]
[180000,250000,0.45]