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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

Total

$1,851.46

$

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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Saunier Duval TC C25E