Electronic Agreement

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Contact Details

Salutation:

First name:

Middle name:

Last name:

Company

Position

Country:

Address:

Suburb:

State/Territory:

Postcode:

Email address:

Telephone:

Mobile:

Please provide either a Telephone or Mobile number.

By registering my information, I declare that, to the best of my knowledge, the details provided above are true and correct and believe that I have, or represent someone who has or may have a claim with respect to the class action described above. I acknowledge that any information disclosed to me as part of this online sign up process may contain confidential information relating to the above class action (Confidential Information). I agree to hold any such Confidential Information in strict confidence and only use Confidential Information solely for the purposes of determining whether to join the class action and/or apply for an interest in any litigation funding scheme established for the class action.

Claimant Details

The claimant is the person or entity who is the holder of the business interruption insurance (“BII”) policy the subject of the claim.

Company

If the claimant (i.e. the person specified as the holder of the policy) is a company, please include the full name of the company and its Australian Company Number (“ACN") below.

Sole Trader

If the claimant (i.e. the person specified as the holder of the policy) is a sole trader, please include the full name of the sole trader and any Australian Business Number (“ABN”) the sole trader operates under. Please also include the date of birth of the sole trader below.

Partnership

If the claim is being made on behalf of a partnership, please include the full name of the partnership and any ABN the partnership operates under.

Trust

If the claim is being made on behalf of a trust, please include the full name of the person or company acting as trustee of the trust, as well as the name of the trust and any ABN the trust operates under. For example, “John Smith as trustee of the Smith Trust, ABN 11 222 333 444”. Please also include the date of birth of the trustee below.

First Name:

Last Name:

DOB: (dd/mm/yyyy)

Email Address:

First Name:

Last Name:

DOB: (dd/mm/yyyy)

Email Address:

First Name:

Last Name:

DOB: (dd/mm/yyyy)

Email Address:

First Name:

Last Name:

DOB: (dd/mm/yyyy)

Email Address:

Full name of claimant:

Claimant Address:

The claimant address is the same as the contact address (entered on the previous screen)

The claimant address is different from the contact address (entered on the previous screen)

Please note that P.O. boxes are not allowed in this section.

Country:

Address:

Suburb:

State/Territory:

Postcode:

Claimant declaration:

You are the claimant, or are acting on behalf of and with authority of the claimant.

Investment Details

In this section, we ask you to provide details of the claimant's trading history in the securities which form part of your claim.

It is important these details are accurate. We suggest you refer to trade confirmation forms and contract notes when completing this section.

Stock Exchange:
(if you have traded in multiple exchanges you are required to complete an additional registration)

Opening Balance:
Please provide the number of securities held as at close of trade on 10-Jun-2021. If you did not hold any securities as at 10-Jun-2021, please write "0"

Trade details:
In the sections below, list all transactions (buys and sells) in the trade collection period for the claim.

The Trade Collection Period for this claim is 11-Jun-2021 to 11-Jun-2021 (inclusive)

Trade Date	Type	Buy/Sell	Stock Code	Quantity	Total Net Amount in AUD (including brokerage)	Price

Investment details declaration:

I confirm the information provided is true and correct to the best of my knowledge.

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Claim Details

Please answer the following questions accurately in relation to your claim:

Omni Bridgeway Funding Agreement

This is the agreement between the Claimant and Omni Bridgeway Limited. To become a client of Omni Bridgeway you must review and accept the terms of the Omni Bridgeway Funding Agreement (Funding Agreement).

We ask that you review the Funding Agreement carefully before entering into the Funding Agreement. If you have any questions about the terms of the Funding Agreement, please contact us at [email protected].

If you enter into the Funding Agreement, you will not have to pay anything, unless the Claims are successfully resolved, in which case the fees are recovered from the Resolution Sum. Omni Bridgeway will pay the other side's legal costs if the class action is unsuccessful and the Claims are lost.

A copy of the Funding Agreement will be emailed to you on completion of this process.

We note that the Funding Agreement is subject to a 21-day cooling off period, in which time you may terminate it by following the notice requirements, as set out in the terms of the Funding Agreement. You may use this cooling off period to obtain separate legal advice about the Funding Agreement if you wish to do so.

Declaration:

By selecting the 'tick boxes' and typing my name below, I confirm that:

I am the Claimant or I am duly authorised to act and enter into the Funding Agreement on the Claimants behalf.

the Claimant has read the Omni Bridgeway Disclosure Statement.

the Claimant has read the Funding Agreement.

the Claimant accepts and agrees to be bound by the terms of the Funding Agreement with Omni Bridgeway.

I acknowledge that Omni Bridgeway will accept this Funding Agreement as containing my signature for the purposes of the relevant electronic transactions legislation.

the Claimant has been given the opportunity to obtain, and has obtained, all independent legal, financial and other professional advice in respect of this Agreement that the Claimant considers necessary.

Please type your name:

Position/Capacity:

Omni Bridgeway Product Disclosure Statement Acceptance

This Application Form relates to the Product Disclosure Statement ('PDS') issued by Omni Bridgeway Investment Management Limited (ACN 642 086 593, AFSL 524023) ('OBIML') as the Responsible Entity (‘RE’), in relation to The QBE BII Claim Litigation Funding Scheme (ARSN 650 744 415) ('Scheme'). Information about the Scheme can be found in the PDS for the Scheme, of which this Application Form is part, or it can be downloaded here: https://portal.omnibridgeway.com/qbe. Please read the PDS, this Application Form, the Claim Funding Terms at the end of the Scheme's constitution, and the Scheme’s constitution itself carefully, as together those documents contain terms that will be binding on you if your application is accepted by the RE.

Declaration:

By selecting the 'tick boxes' and typing my name below, I/we declare and agree that I/we:

have read and understood in full the PDS and the Scheme’s constitution (including the Claim Funding Terms in Schedule 3 of the Scheme’s constitution) (collectively, the ‘Scheme Documents’), copies of which are available at https://portal.omnibridgeway.com/qbe;

agree that the terms and conditions of the Scheme Documents form part of this declaration and agree to be bound by the Scheme’s constitution;

by signing this declaration, represent that I/we am/are eligible to be a funded member of the Scheme and agree to make the Assignment referred to in the Scheme’s constitution;

agree that all of the information provided in my/our application is true and correct and I/we undertake to inform you of any changes to the information supplied as and when they occur;

acknowledge that this application may be submitted electronically and that such electronic version shall be legally binding;

warrant (if applicable) that I/we have authority to sign this Application Form on behalf of the claimant;

agree that OBIML may contact me/us where required by using the email address provided on this Application Form;

acknowledge that OBIML may require us to provide any additional documentation or other information to enable compliance with any laws relating to anti-money laundering and counter terrorism financing (‘AML/CTF’) or any other law, including the Foreign Account Tax Compliance Act ('FATCA') and OECD Common Reporting Standard (‘CRS’); and

agree to sign and return a copy of the Retainer Agreement with Gordon Legal Pty Ltd, on the terms set out in Schedule 2 of this Application Form.

Please type your name:

Position/Capacity:

Registration Acceptance

By electronically accepting the below conditions you will agree to register your potential claim for inclusion in the BII QBE Class Action and for the purpose of any possible settlement.

A copy of the completed registration form will be emailed to you on completion of this registration process.

It is important that following your registration you send 3rd party supporting documentation, such as contract notes, for each of the share transactions included in your claim to [email protected].

Declaration:

I confirm that:

I am the Claimant, or I am duly authorised to act on the Claimants behalf.

I acknowledge that electronic acceptance has the same effect as signing a hard copy version of the registration form.

I acknowledge that Omni Bridgeway Limited will accept this registration form as containing my signature for the purposes of the relevant electronic transactions legislation.

Please type your name:

Position (if applicable):

Solicitor Retainer

This is the retainer agreement between the Claimant and the Lawyers ("Retainer Agreement").

As you have accepted the terms of funding set out in the PDS, you will not have to pay any Lawyer's fees if the class action proceeds, unless claims are successfully resolved, in which case the fees are recovered from the Resolution Sum. There are no "out of pocket" fees payable by you.

A copy of the Retainer Agreement will be emailed to you on completion of this registration process.

Declaration:

By selecting the 'tick boxes' below and typing my name below, I confirm that:

I am the Claimant or I am duly authorised to act and enter into the above Retainer Agreement on the Claimant’s behalf.

I have read and understood the terms of the Retainer Agreement with the Lawyers.

I accept and agree to be legally bound by the terms of the above Retainer Agreement with the Lawyers.

This electronic acceptance has the same effect as if I had signed a hard copy version of the Retainer Agreement.

I expressly consent to this method of acceptance of the terms of the Retainer Agreement in accordance with s10(1) of the Electronic Transactions Act 2011 (WA) or the relevant corresponding State or Territory legislation.

Please type your name:

Position (if applicable):

Claim Complete

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Contact Details

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Claimant Details

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Investment Details

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Documents

Claim Details

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Omni Bridgeway Funding Agreement

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Omni Bridgeway Product Disclosure Statement Acceptance

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Registration Acceptance

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Solicitor Retainer

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Claim Complete