South Australian Employment Tribunal

Form A21 – Application - Dust Disease Civil action

Form A21

Application - Dust Disease Civil action

Case Number
(SAET use only)

About this form

  • This is the approved form to commence proceedings in the South Australian Employment Court under the Dust Disease Act 2005. This form will also commence an action for damages in respect of a dust-related condition pursuant to Section 3(2) of the Survival Of Causes Of Action Act 1940.
  • The form ‘Statement of claim - Civil action’ may be lodged with this formbut can be lodged later. The Statement of Claim must, however,be provided within 21 days of service on any party and no later than 6 months after lodgement.
  • Upon lodgement of this form, the matter will be listed for a Directions hearing within 7 days or earlier.
  • A ‘Summons fee’ is payable to SAET before proceedings can commence. Go to for more information regarding fees.
  • Submitting an incomplete form (including any relevant supporting documents) may result in delays.

Urgency of Matter

Do you require a hearing in less than 7 days? / ☐ No ☐ Yes - no later than (please specify):

Endorsement of claim

Due wholly or partly attributable to a breach of duty owed to <specify whether the person who suffered the disease is the applicant of some other person> by the parties named herein, the application claims damages:

☐ for or in relation to: (specify the relevant disease(s) below)

or

☐ for the death of as a result of: (specify the relevant disease(s) below)

Party details

Applicant

Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country
Do you require an interpreter? / ☐ No ☐ Yes. Please specify language:
Do you have any special requirements which will require assistance? / ☐ No ☐ Yes. Please specify:
Is anyone representing you? / ☐ No ☐ Yes. Please specify:

Representative detail (if required)

Organisation
Contact First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

To be served on

Organisation
Contact Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

Other party

Organisation
Contact Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
AddressStreet 1
Street 2
Suburb / State
Postcode / Country

Fees

District Court (civil) fees are payable in these proceedings. For up-to-date fees, refer to the District Court (Fees) Regulations 2004 or go to for more information.

Fee type / Amount payable / $

Payment options

☐ State Crown exempt
/ Exempt from paying fees under the Crown Proceedings Act 1992
☐ Credit card(visa or MasterCard)
/ Online - go to
Phone - call SAET Registry on 08 8207 0999
Provide your receipt number for reference:
☐ Electronic Funds Transfer (EFT)
/ Acc name: AGD Corporate Account
BSB: 065-266
Acc No: 10019434 / Please include “SAET-<your name>” in the bank reference field
Date transfer made:
☐ Cheque
/ Make cheques the “South Australian Employment Tribunal” and submit by:
In person - Registry, Level 6, Riverside Centre, North Terrace, Adelaide, 5000
Post - PO Box 3636, Rundle Mall, SA, 5000 (enclose a copy of this form)
SAET USE ONLY

Declaration and lodgement

I declare that:

☐ All of the facts in this application are true and accurate to the best of my knowledge and belief.

☐ I have completed and attached a Statement of Claim - civil action form(s)

☐ I have paid (or taken appropriate steps to pay) the required fee

☐ I will send a copy of this application and accompanying documents to the defendant.

Name of person lodging
Signature
Date

Please lodge this form, together with any accompanying documents, with the South Australian Employment Tribunal:

Email:
Post: PO Box 3636, Rundle Mall, SA, 5000
In person: Level 6, Riverside Centre, North Terrace, Adelaide, 5000

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR OWN RECORDS

SAET Registry: 08 8207 0999