camer INJURIES COMPENSATION APPLICATION - FORM 1 to complete tis form. "The Act refers to the Criminal FETS Saw aAless the person on whose behalf the application is made. Z LEE 51 _jury (boty harm, mental and nervous shock or pregnancy. G1 _Loss arising from death (uneral expenses or loss of nancial suppor). IF SO.USE FORM 2 for that claim. T_ Neither (you are nt etaibe for compensation unless you were inured inthe commission ofan offence, or sulfred loss when a cose relative cles). TY Yourset _Aparent or person in place of a parent fora child under 18 years of age. TA person with a disability as the person's guardian or administrator (provide copes of your author), T1_The personal representative of a deceased person IF SO, USE FORM 2 for that claim. Provide the detais of the applicant: ae ae 5 zB ae Male O Female other O Sumame: Whit-¢{2\ ad Given Namels: TAIUYY Lind AY ~G{A@ Date of Binh: 14 7 & 1144 G pesto stvget Avoleg wA 66064 Home: 7 Mobile: OF VASUNT SO [Work 7 “Fis ibe ba dle ied fame ith ou wes anv eqesied TaiIVY -whitc\2id @ email. com 5 aa z Licence No: ¢ 024% ‘Occupation: en Name: Relationship to you! Phone’ Tis wile tha detail mtfed of communication ules aharwoe requested ‘Surname: ‘Given Namels: DateofBinh TT Home! Mobile: Work: “is lb he Stat meted ef commucaling wih you wiess aterise roasted | Ci Parent 11 A person with a disablity 2s the quardian or administrator (provide copies of your authority) Firm Name: Practitioner Name: weO ws 0 Address: "His willbe fe dla miedo canmuraon lose Shenae equated Lawyers reference: IMPORTANT NOTICE: The Office of Criminal Injuries Compensation maintains records in electronic format. Please ensure you keep copies of all documents you submit, and submit only a copy of any document you need to retain. All documents submitted with your application will be destroyed when your application has been finalised. 1|Page 46 Fiease provide date afinedent. 1% January 2020 7 Did the incident, or the last incident Dyes i No: The Act states an application should be lodged within 3 years from the date of the incident or the last incident involving the same offender. Please attach a signed statement explaining why your applicaton is lodged outside of tis tme. 2% WEXcOmMeeE wAY, AVELEY Di vee Name sf aes Canpesatonnewanet | csn number Oves Insurance Commission of WA Claim Number: (e.g. assault, sexual offence, murder etc.) ASSEN Ti ityes: Attach a copy, you can obtain a copy of your statement from WA Police. To: Piease attach a signed statement detaing the incident. O Yes PoleerPubic Transport Autoiy/ Rail Eo: Give a statement detaing the incident and explaining why a report was not made. i ityes: Provide the Incident Report number ONo NIP Tes: Give details below Surname: AGRA GoASA\\ Sumame WW LGR V Given Namels Racwa\\D | GwenNamess Pay [Yes Please give details ofthe offender's’ whereabouts both 1V2 at 22 welcome? way, Aveliy O ves No D1 Unknown NIP Yes: What wasivere the chargels? in7y Th Yes CINo: When i the next Court date? vie Di Magistrates Court 1D District Court C1 Supreme Court Oi Children's Court CO cuitty Di Unknown Gi not cuity 1 Date of the outcome Dyes — ONo Dl How much? Has any been received: Cl Yes CINo ifso,howmuch? $. uy‘The maximum interim payment is $2,250.00 for an incident after 1 January 2003. Yes: Select the options that best describes your application for an interim payment 1 I need treatment expenses paid 1 Ineed ambulance expenses paid 1 I need to obtain a report (medical, dental or psychological), | need funeral expenses paid for a deceased close relative IF $O,USE FORM 2 for that claim, Claims for injury SVE SE Eq body harm, mental and nervous shock or pregnancy injuries? Atach a statement ofthe injures you suffered and the impact of your injuries on you Include secent photos showing any scars if appropriate [25 Provide documents Ti Reporis trom your treating healthcare professionals (atach the relevant reports) to demonstrate the | injuries you suffered TaHospitalis and health care provider's where you received treatment. Name ofheath care powder [Clava Gradvin [___ Name of hospitalipractioe: STO@ midlawd ‘Address of hospitaipracice: 1 deoten St) midland Contact number of practice: AYE? Yoo Names ofheath care prover [Dy Puan LiSiZ Names of hosptalipractioe Motluwood tmadical camry "Address of haspital/practice: 2[ 6 Monach AVE, Nedlands Contact number ofpracice: | q2Qq S84>H Ci None of the above. if you dd not have any restment attach a signe statement explaining why. Claims for Reports (medical, dental, psychological, counseling) {26 if you are claiming the cost of reports, complete the table below and aitach Invoices to support your claim. Reference | Date | Name ofthehealth care professional | Cost of tho report |__ Has the report been paid umber provided [Yes [No 4__[23[e fro | OY Poan Liste 31S cal eee eae | a a 3. a ao] cs a ——| 5. Oo a Ifyou want te Glaim an inlerim payment for 6 fepor you have already obtained complete the table below. Include the reference number and health care professional detalls noted in | Select who should receive the interim payment question 26 for the report for which_you wish to claim an interim payment Reference ‘Name of the health care professional You Health Care’ ‘Other ‘number Professional | (paren, ewer) T = | cofelalal dlojaloyal alolalala| _ | = =a] 27) if you want to claim an jet payment for a repor(s) thal you have not yet obtained complete the table below and attach eS ‘Name of the health care professional who will provide the report geese ae Feport ee| cians for Travel Expenses” Vou can olla for travel expanses which were incured to obtain treatment. These must be ‘supported by accounts, receipts and reports. 28 Tf you are claiming for avel expenses complete the lable below and ensure the accounis, eceipis and reports you have povided supoett your clam for exch Jou Date | Name of the health sing location Destination Total number of Far Care cokeceioral (orovide address) (provide address) kilometres return | (Gus, Trin, ip ‘Ambulance and private vehicle) Tax Claims for Treatment Expenses: Ifyou ate claiming for veatmient expenses, you must first claim all available private health insurance ‘and Medicare rebates. Complete the Table below and ensure you provide copies of each Invoice, receipt and rebate. /29 Doyouhave private health | EV’ Yes: Provide the name of your private health insurance fund below. Ono insurance? ALE Reference | Date | Name ofthehealth | Service provided] Costof | Private health | Medicare” [Gap number ‘eare professional the Febate | (Costless service amount | rebate provided received | 2mou) received | (i applicable) (i appicabie) 7 PsfolPoant isi | consul e $180 | $6 Pa $105 2 t 3. — 4 5 = 6. 7. : . - a. | t 10. I I 30. Complete the table below if you want an interim payment fora treatment expense you have already incurred. Include the reference number and health care professional details noted in question | Select who should receive the Interim 29 for treatment for which you wish to claim an interim payment. payment Reference ‘Namo of the health care professional You | HealthCare | Other number Professional | (ea paren) a a oz a a sere = — a a [5 a i a a t a a '31) Complete the table below f you want o claim an interim payment for reaiment expenses you have not yat Incurred for wealment you wish fo undergo before your application's finalised ‘Name of the health cafe professional who will Coat ofthe provid6 the treatment ‘Treatment required Eetoned 4|PagyD1 Yes: Select the options that best describes your ciaim. 1 Lose of income: Loss of earning capacity 11 Yes: Provide a detailed statement and provide the documents requested below after question 35. Ensure the claim is supported by the reports, and brielly descrive the income you are currently prevented from eaming andlor are going to be prevented for earning inthe futur. Al andl future) 34 Did you receive any Ono, Reape ees fast the options that describe how you were paid and provide documents in support Srccloave or other pai eave (9 enval lav) CO. Centrelink benefit Cl Workers’ compensation C1 Personal accident or income protection insurance 1 other form of income support. Please attach a signed statement giving detalis, <—~_ 35. How much income Tiners_ 6816-96 Cersss_4,654 47 Cx did you receive? mont -) include cones ofthe folowing documents as pat of your Gaim for joss of nears I Televant Pay sips (6 weeks before the incident and all ay slips eter the incident when your income was affected) 1B Copies of your tax returns for he 3 years before the incident and all since the injury 1 Loter tom your employer detaling your pre-inident average nel earings, hours worked and any peld leave Claims for Personal item phone etc ‘36. Ifyou want to claim for any personal items (cloths ‘spectacles, hearing ald, artificial imbs) which incident, complete the table below, foi aré not enilied fo Compensation for the Value of lost or Stolen property Such as jawellery, wallet footwear, ‘damaged in the HenyDamaged Detail the damage andhow | Estimated valuel itwas caused replacement cost, Claims for Provision for Future Treatment Expenses ‘37. Are you likely to incur expenses for freaimen after your | Yes: Provide deals ofthe nature of he treatment, the expected costs and any avaiable private application has health insurance or Medicare rebates and atach a leterrepod fom your health care professions 29, denial, counseling oe 5|Page‘Bank Account Details If your claim is successful, payments can be made via elecionic funds transfer (EFT) to your or your lawyer's bank account. Provide your bank details below if you wish to receive EFT payment. If you do not wish to receive funds via EFT a cheque will be sent to the address given in question 3 or 4 “Account Name TL Wh hi Wa AccountNumber | CRY YoTuUSO AOS [BsBNumber[Q 0 G6 oo OG” Ifyou would ike money paid to Someone olse (@.g.@ Service provider) Complete the autho for the Office of Criminal Injuries Compensation to make payments to another person on your Beha fm your compensation. : ‘Amount ta be paid ‘Address or EFT details of the person you would ike sah a = ie : Pe z ~OR i z ‘Account Name: EFT ae “petais | AecuntNurbee —_ [BSBNumber: a z Date PART E: DECLARATIONS ‘Select the section of the Criminal Injuries Compensation Act 2003 under which your claim is made. ‘Section 12: Proved offence — offender convicted ‘Section 13: Alleged offence = accused acquitied, applicant claims another parson commilfed the offence ‘Section 14: Alleged offence — accused acquitted due fo unsoundness of mind ‘Section 15: Alleged offence — accused not mentally fil stand tral ‘Section 16: Alleged offence = charge not determined ‘Section 17: Alleged offence — no person charged. “Acknowledgement of Application. ifyou would ke the Ofce of Criminal Injuries Compensation io acknowedge receipt of your application, pleese tick the check box. Acknowledgement willbe sent via your preferred method of communication (email or post). Ensure you have provided this information in part A of this application, Tunderstand that: ‘+ the assessor will give writen notice of the making of my application to the offender, and may if requested provide copies of supporting documents to the offender, ‘+ the assessor may seek and receive further information and evidence from any other sourcels the assessor thinks necessary; ‘+ Itis an offence knowingly to give false information in suppor of an application for compensation, the maximum penalty for which is 2 fine of $5,000; “+ the assessor may deduct from any compensation any amount | owe under a compensation reimbursement order; + the assessor may be required to pay any debt | owe to the Fines Enforcement Registy (FER) cut of any compensation awarded; “+ the documents submitted with this application will be destroyed after finalisation of the application and only electronic copies will be retained; ‘+ must keep a copy of the documents submited with the application. @ | [Rgploolo Re Twit ci2id ae | 24/06 12020 wee HOW DOT LODGE MY APPLICATION? El dune eiesauicies Teste fiiticti Tasco ees eS eteenels aesieles=apeAWUACS EN ‘Application Form 160318 ec eyEmployee ID: Fortescue Employer: Taken focenban Oe ¥ Tailyr Lindsay-Grace WHITFIELD 570321 FMG Training Pty Ltd 93 158 710 395 01/03/2020 to 31/03/2020 15/03/2020 Cloudbreak Apprentices Apprentice Heavy Mobile 5 Pesto Street Equipment AVELEY WA 6069 TFR: $ 128,330 Payment Details Earnings Days/Units Amount. Base Salary 7,134.42 Shift Allowance 833.33 Site Allowance 1,660.67 Total Gross Pay 9,634.42 ‘Share Pian (Sal Sac) 166.67- Total Deductions (Before Tax) 166.67- Total Taxable 9,467.75 Full Income Tax 2,652.00- Total Tax 2,652.00- Nett Pay 6,815.75 FORTESCUECORPORATESUPER 1201337505816 1,089.79 ‘Company Superannuation Contribution 1,089.79 ‘Account Holder BSB Account “Amount Tailyr Lindsay-Grace WHITFIELD 086-006 349487966 6,815.75, Pay Summary This Pay YeartoDate [Leave Entitlement Balance Total Gross Pay $ 9,634.42 97,713.33 | Annual (days) 7.68 Total Deductions (Before Tax) $ 166.67- __1,500.03- | Long Service (days) Total Taxable $ 9,467.75 96,213.30 Total Tax $ 2,652.00- 28, 158.00- ict: yourleaveeniements are as of Total Payments (After Tax) 8 0.00 0.00 fhe current month; any future dated Total Deductions (After Tax) $ 0.00 0.00 Absences have not been deducted. Nett Pay $ 6,815.75 68,055.30 Company Superannuation Contribution $ 1,059.79 10,748.48 MessagesEmployee ID: 570321 Employer: FMG Training Pty Ltd Fortescue ABN: 93 158 710 395 - From: 01/02/2020 to 29/02/2020 Pay Date: 15/02/2020 : Org Un Clouabreak Apprentices Tailyr Lindsay-Grace WHITFIELD Posit Apprentice Heavy Mobile 5 Pesto Street Equipment AVELEY WA 6069 TFR: $ 128,330 Payment Details Earnings Days/Units Amount Base Salary 7,134.42 Base Salary 01/01/2020 4,609.94- Shift Allowance 833.33 Shift Allowance 01/01/2020 538.46- Site Allowance 1,666.67 Site Allowance 01/01/2020 1,076.92- Annual Leave 26/01/2020 to 26/01/2020 1.00 444.66 ‘Annual Leave 27/01/2020 to 29/01/2020 3.00 1,393.98 Personal Leave 16/01/2020 to 17/01/2020 2.00 889.32 Personal Leave 18/01/2020 to 19/01/2020 2.00 389.32 Personal Leave 20/01/2020 to 25/01/2020 6.00 2,667.98, Total Gross Pay 9,634.34 Share Pian (Sal Sac) 166.67- otal Deductions (Before Tax) 166.67- Total Taxable 9,487.67 Full Income Tax 2,652.00- Total Tax 2,652.00- Nett Pay 6,818.67 FORTESCUE CORPORATE SUPER 1201337565616 1,059.78 ‘Company Superannuation Contribution 1,059.78 ‘Account Holder BSB Account “Amount Tailyr Lindsay-Grace WHITFIELD 086-006 349487966 6,815.67 Pay Summary This Pay YeartoDate |Leave Entitlement Balance 9,634.34 88,078.91 | Annual (days) 5.56 Total Gross Pay Total Deductions (Before Tax) Total Taxable Total Tax Total Payments (After Tax) Total Deductions (After Tax) Nett Pay Company Superannuation Contribution s $s s s s s s s 166.67- —1,333.36- 9,467.67 86,745.55 2,652.00- 25,806.00- 0.00 0.00 0.00 0.00 6,815.67 61,239.55 1,059.78 9,688.69 Long Service (days) Note: your leave entitlements are-as of kine curent month: any future dated lavsences have not been deducted Messages:& Fortescue ‘Tailyr Lindsay-Grace WHITFIELD Employee ID: 570321 FMG Training Pty Lid 93 158710 395, 01/12/2019 to 31/12/2019 15/12/2019 Cloudbreak Apprentices Apprentice Heavy Mobile 5 Pesto Street Equipment AVELEY WA 6069 TFR: $ 128,330 Payment Details Earnings Days/Units Amount Base Salary 4,829.45 Shift Allowance 564.10 Site Allowance 4,128.21 ‘Annual Leave 12/12/2019 to 15/12/2019 4.00 1,778.64 Annual Leave 16/12/2019 to 18/12/2019 3.00 1,339.98 Total Gross Pay 9,634.38 Share Plan (Sal Sac) 166.67- Total Deductions (Before Tax) 166.67- Total Taxable 9,467.71 Full Income Tax 2,652.00- Total Tax 2,652.00- Nett Pay 6,015.71 FORTESCUE CORPORATE SUPER 12013337565816 1,059.78 Company Superannuation Contribution 1,059.78 ‘Account Holder BSB Account “Amount Tailyr Lindsay-Grace WHITFIELD 086.006 349487966 6,818.71 Pay Summary Total Gross Pay $ Total Deductions (Before Tax) $ Total Taxable $ Total Tax $ Total Payments (After Tax) $ Total Deductions (After Tax) $ Nett Pay $ Company Superannuation Contribution $ Messages This Pay YeartoDate [Leave Entitlement Balance 9,634.38 166.67- 9,467.71 2,652.00- 0.00 0.00 6,815.71 1,059.78 68,810.18 | Annual (days) 11.47 1,000.02- | Long Service (days) 67,810.16 20,202.00- note: your leave entitlements are as of 0,00 the current month; any future dated 1000. fbsences have not been deducted. 47,608.16 7,569.13Employee ID: 570321 Employer: FAG Training Pty Lid Fortescue ABN: 93 158 710 395 From: 01/01/2020 to 31/01/2020 ’ Pay Date: 15/01/2020 Org Unit: Cloudbreak Apprentices Tailyr Lindsay-Grace WHITFIELD Position: Apprentice Heavy Mobile 5 Pesto Street Equipment AVELEY WA 6069 TFR: $ 128,330 Payment Details Earnings Amount Base Salary 5,158.74 Shift Allowance 602.56 Site Allowance 4,205.13 Annual Leave 03/01/2020 to 06/01/2020 4.00 1,778.64 ‘Annual Leave 07/01/2020 to 08/01/2020 2.00 889.32 Total Gross Pay 9,634.39 Share Plan (Sal Sac) 166.67- Total Deductions (Before Tax) 166.67- Total Taxable 9,467.72 Full Income Tax 2,652.00- Total Tax 2,652.00- Nett Pay 6,815.72 FORTESCUE CORPORATE SUPER 12013337565816 1,059.78 ‘Company Superannuation Contribution 1,059.78 ‘Account Holder BSB Account ‘Amount Tailyr Lindsay-Grace WHITFIELD 086-006 349487966 6,815.72 Pay Summary This Pay YeartoDate |Leave Entitlement Balance Total Gross Pay $ 9,634.39 78,444.57 | Annual (days) 7.58 Total Deductions (Before Tax) 8 166.67- __1,166.69- | Long Service (days) Total Taxable $ 9,467.72 77,277.88 Total Tax $ 2,652.00- 22,884.00- \Note: your leave entitlements are as of Total Payments (After Tax) 8 0.00 0.00 fine current month: any future dated Total Deductions (After Tax) 8 0.00 (0,00 absences have not boon deducted, Nett Pay S$ 6,815.72 54,423.88 Company Superannuation Contribution $ 1,059.78 8,628.91 Messages