Apply for Workman’s Compensation Workman’s Compensation Registration 1APPLICANT INFORMATION2COMPANY INFORMATION3EMPLOYEES INFORMATION4UPLOAD DOCUMENTS5REVIEW UPLOADED DOCUMENTS6REVIEW COMPLETE APPLICATION7SUBMIT APPLICATION Application IDApplicant informationName and surname*Applicant E-mail address* Cell number* Company informationCompany/CC Name*Company/CC Registration Number*Company/CC AddressPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Business DescriptionPAYE Number (if applicable)UIF Number (if applicable)Number of Directors*0123456789101112131415Director 1Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 2Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 3Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 4Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 5Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 6Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 7Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 8Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 9Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 10Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 11Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 12Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 13Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 14Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 15Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Employees InformationNumber of employees*OneTwoThreeFourFiveSixSevenEightNineTenElevenTwelveThirteenFourteenFifteenSixteenSeventeenEighteenNineteenTwentyEmployee 1Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 2Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 3Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 4Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 5Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 6Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 7Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 8Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 9Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 10Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 11Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 12Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 13Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 14Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 15Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 16Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 17Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 18Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 19Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 20Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year* Do you want to upload documents?* Yes No Documents Upload* Drop files here or Select files Accepted file types: jpg, gif, pdf, doc, docx, xls, xlsx, Max. file size: 2 MB, Max. files: 5. Allowed Formats: jpg, gif, pdf, doc, docx, xls, xlsx Max File Size of Each Document Should be 2MBMax Number of Files Allowed is 5Documents Required as Below:1. Company documents2. Director/Member certified ID copiesPlease Note: If these files are too large to upload, please send it to info@registeryourbusiness.co.za, using your Company/ CC name as the subject. Do you want to review your uploaded documents?* Yes! I want to see my uploaded documents No, I don’t want to see my uploaded documents Click on below link to preview your uploaded documents {Image Format Upload:266} Do you want to review your application?* Yes! I want to review my application No, Its Fine Please Review Your Application As Below {all_fields} Submit ApplicationI confirm all information to be true and correct in all aspects and I agree to the registration terms and conditions. Yes No Would You Like COID Registration and Letter of Good Standing?*COID Registration – R1199.00 COID Registration and Letter of Good Standing – R1599.00 No Yes Total payableTotal R0.00 Payment Method* EFT Credit / Debit Card Banking Details Bank:FNBAccount Name:Register Your BusinessAccount Number:627 1367 7493Branch Code:250 655 NameThis field is for validation purposes and should be left unchanged.