The plaintiff, as the Workers Compensation Nominal Insurer, provided workers compensation insurance to the defendant under policy number [redacted] for the period of July 14, 2011 to July 14, 2012. The estimated insurance premium for this period was $1,851.46. Under the Workers Compensation Act and the insurance policy, the defendant is liable to pay this amount plus ongoing interest as prescribed by the Act until payment. The plaintiff is claiming the $1,851.46 premium, continuing interest until judgment, and costs.

1. PLEADING AND PARTICULARS
1. At all material times, the Plaintiff was or is to be taken as having been the Workers
Compensation Nominal Insurer pursuant to Section 154A and Schedule 6 of the
Workers Compensation Act 1987 ("the Act").
2. For the period(s) specified in paragraph 4 the Plaintiff held the Defendant insured and
indemnified pursuant to the provisions of the Act in terms of workers compensation
insurance policy no. ("the policy"). .
3. Pursuant to the Act the Plaintiff is entitled to a late payment fee (referred to in this
Statement of Claim as "interest") on unpaid insurance premiums at the relevant rate
as prescribed pursuant to the Act from time to time continuing until payment.
4. Pursuant to the Act and the policy the Defendant is liable to pay the Plaintiff insurance
premium and interest as follows:
a) estimated premium for the period of insurance
14 July 2011 to 14 July 2012 $1,851.46
Total $ 1,851.46
AND THE PLAINTIFF CLAIMS:
(a) the sum of $1,851.46;
(b) continuing interest pursuant to the Act as per 3 above from until judgment;
and
(c) costs.
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