Step 1 of 3 33% Unique IDForm Edit NumberAdero Notes1. Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last 2. Phone*3. Email* Enter Email Confirm Email 4. Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 5. Date Of Birth* Date Format: DD slash MM slash YYYY 6. Were you employed as a casual miner by Stellar in the black coal industry between 21 December 2012 and 21 December 2018?*YesNo7. Enter the number of mine sites you worked at:*12345678 8.1 - Please enter the name of the mine site you worked at for the longest period of time:*8.2 - Please enter the name of the mine operator:8.3 - Start Date at Mine Site: Date Format: DD slash MM slash YYYY 8.4 - End Date at Mine Site: Date Format: DD slash MM slash YYYY 8.4.1 - Number of days at mine site:The start date is later than the end date, please adjust your selection.8.5 - Position at Mine Site:8.6 - Start Hourly Rate:8.7 - End Hourly Rate:8.8 - Roster Cycle:8.9 - Roster Provider:Mine OperatorStellar8.10 - Was your roster provided on a long-term advanced basis setting out the shifts you were required to work?YesNo8.11 - Did you complete your own timesheets, as opposed to them being prepopulated with your shifts by Stellar?YesNo8.12 - Did Stellar or the mine operator provide you your work-related instructions?Mine OperatorStellar8.13 - While working at the mine site(s) did you suffer the loss of an immediate family or household member, or did an immediate family or household member contract or sustain a personal illness or injury that posed a serious threat to their life, and you took unpaid leave as a result?:YesNo8.13a - Please provide details (including date(s)) and evidence (such as a medical certificate(s))8.13b - Provide any supporting documents: Drop files here or 8.14 - While working at the mine site(s), did you ever take time off due to sickness for which you were unpaid?YesNo8.14a - Please provide details (including date(s)) and evidence (such as a medical certificate(s) or request for a day off form(s)):8.14b - Provide any supporting documents: Drop files here or 8.15 - Have you ceased working (e.g. you resigned or decided to end your employment) at the mine site(s)?YesNo8.15a - Were you paid accrued annual leave entitlements?YesNo8.15b - Were you paid accrued personal leave (e.g. sick leave) entitlements?YesNo8.16 - Was your employment at the mine site ever terminated with no notice or were you made redundant (e.g. by way of a “change of shirt”) by Stellar?YesNo8.16a - Did you receive a termination payment and/or redundancy payment?YesNo8.16b - Please provide details (including date(s) of your employment ending and the reason given for any termination)8.17 - Please upload copies of any contracts of employment, letters of offer, payslips, rosters or other relevant documentation: Disclosure Letter By signing below and submitting this form you: reasonably believe that you will be eligible to participate in the action; warrant that; the information you have provided is true and correct; and you will not sign-up or register using any false or misleading details; hereby execute and agree to be bound by and comply with the terms of the; Retainer Agreement; and Funding Agreement and consent to us entering the information you have provided to us into those documents have been given the opportunity to obtain independent legal advice as to the nature and effect of the Retainer Agreement and Funding Agreement, and you agree to be bound and comply with the terms of the Retainer Agreement and Funding Agreement; after obtaining, and in reliance on such independent legal advice; or having elected not to obtain independent legal advice; and you have read and understood the nature and effect of the Retainer Agreement and Funding Agreement; and you do not require any explanation or advice in relation to those documents; consent and authorise us to use the information provided to assess whether or not you may be eligible to participate in the action; and consent to receive further communications from us regarding any continued participation in the action. Signature*Consent* I agree to the terms and conditionsIf you would prefer to sign a hard copy of this agreement, please print out a copy of the Retainer Agreement and Funding Agreement, complete the Claimant Details in the document, sign it, and then scan it as a PDF and email it to: stellaraction@aderolaw.com.au. I understand that the Retainer Agreement and the Funding Agreement are confidential documents. I understand that I am not permitted to share these documents or the information contained therein with any third party or for any purpose other than participating in the proposed proceedings. If you would prefer to sign a hard copy of these agreements, please print out copies of the Retainer Agreement and Funding Agreement, complete the Claimant Details in each document, sign them, and then scan them as a PDF and email them to: stellaraction@aderolaw.com.au
