Notice Form Of Appeal From Review Division - Compensation Decision
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1
2WCAT
NOTICE OF APPEAL
Workers’ Compensation
FROM REVIEW DIVISION
Appeal Tribunal
Compensation Decision
150 - 4600 Jacombs Road, Richmond, British Columbia, V6V 3B1
Telephone: (604) 664-7800 Toll free: 1-800-663-2782
Fax: (604) 664-7898 Website:
You must complete, sign and return this form to WCAT within 30 days of the Review Division decision being appealed. Make
sure that you answer every question. We only require the basic information on this form to start your appeal. You will have an
opportunity later on to provide more information to support your appeal. If you are sending this form after the 30 day time limit you
also need to apply for an extension of time to appeal. You can find the Application for an Extension of Time to Appeal on our website
( ) under the Forms tab, or call us and we will send you the form.
11. WORKER CLAIM INFORMATION
Worker Last Name
Worker First Name
Mr. or
Ms.
WorkSafeBC Claim Number(s)
2. INFORMATION ABOUT YOU (APPELLANT)
To keep your appeal active you must tell us about changes in this information.
I am the worker
I am the dependant of a deceased worker
Employer Firm Name
Job Title of Employer Contact named below
I am the employer
My Last Name
My First Name
Mr. or
Ms.
Mailing Address
City/Town
Province
Postal Code
Telephone (Daytime)
Telephone (Other)
Fax Number
(
)
-
(
)
-
(
)
-
A Review Division decision may decide more than one request for review. List below each Review
3. REVIEW DECISIONS
Reference # you are appealing.
Review Division Reference #(s):
R
R
R
R
R
1)
2)
)
4)
5)
3
Date of Review Decision you are appealing (YYYY-MM-DD)
Please attach a copy of the first page of
Copy is attached
the Review Division decision.
4. REASON FOR APPEAL
Provide a brief answer for each Review Reference # you wish to appeal.
The decision is wrong or should be changed because:
(please attach additional page(s) if necessary)
5. RESULT/BENEFITS REQUESTED FROM APPEAL
Provide a brief answer for each Review Reference # you wish to appeal.
I request the following result or benefits from this appeal:
(please attach additional page(s) if necessary)
6. WorkSafeBC DISCLOSURE
Your copy of the WorkSafeBC file will be sent in CD format unless you request a paper copy.
CD COPY
PAPER COPY
WCAT – 1W (Rev: 12June2013) Page 1 of 2
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