Fillable Notice Form Of Appeal From Review Division - Compensation Decision (Page 2 of 2) in pdf

Worker Last Name __________________________________________ WorkSafeBC Claim Number(s) ______________________________

7. METHOD OF APPEAL

WCAT will decide how your appeal will proceed. Please indicate your preference below:

In writing (through written submissions)

Verbally (at an oral hearing)

If requesting an oral hearing, tell us why an oral hearing is necessary:

If WCAT decides to hold an oral hearing, I would like it to take place in:

Castlegar

Cranbrook

Kamloops

Nanaimo

Richmond

Victoria

Courtenay

Fort St. John

Kelowna

Prince George

Terrace

Williams Lake

NOTE: WCAT provides professional interpreters. Family and friends may not interpret for you. If an oral hearing is held, do you need an interpreter?

Yes the language I speak is _____________________________________ Dialect ___________________________________

If an oral hearing is held, do you plan to bring any witnesses to the hearing?

Yes

You may appoint one person or an organization to represent you or choose to represent yourself.

8. REPRESENTATION

Please indicate your choice below.

Will you be representing yourself?

Yes (go to next section)

No (please choose one of the following):

Name of Organization

I want to appoint an organization as my representative

Relationship to Person (e.g. family member or friend)

I want to appoint one person to represent me

Last Name of Representative/Organization Contact

First Name of Representative/Organization Contact

Mr. or

Ms.

Mailing Address

City/Town

Province

Postal Code

Telephone (Daytime)

Telephone (Other)

Fax Number

(

)

(

)

(

)

This form must be signed by the appellant or an authorized representative. If signed by an authorized representative we need an authorization less than

2 years old signed by the appellant. An Authorization of Representative form can be found on our website ( ).

That authorization

is enclosed.

is on the WorkSafeBC file.

9. CERTIFICATION AND AUTHORIZATION

I confirm the information on this form is correct and complete. I will notify WCAT if I change my address or phone number. I understand that WCAT must

have my current address to keep my appeal active. I authorize my representative named above to act on my behalf in this appeal.

For workers: I authorize disclosure of my claim file(s) and information relating to this appeal to WCAT, my representative, and other parties to this appeal

for the purposes of this appeal and as allowed under section 260 of the Workers Compensation Act. I also authorize WCAT to obtain or view from any

source a copy of my employment or medical records or any other documents that may relate to the Review Division decision.

Date Signed: (YYYY-MM-DD)

Signature of appellant or authorized representative

10. FORM CHECK-LIST

Number of additional pages attached? ___

Did you provide Worker Last Name and WorkSafeBC Claim Number(s) on the top of this page?

Did you attach a copy of the first page of the Review Division decision(s) you wish to appeal?

If your appeal is later than 30 days, did you attach a completed Extension of Time to Appeal form (found at

or call us for one)?

Have you signed in Box 9 above?

Did you answer all questions? Call us if you need help filling out this form. Send this form as soon as it is complete.

Personal information on this form is collected for the processing and adjudication of a WCAT matter under the Workers Compensation Act and the

Freedom of Information and Protection of Privacy Act. For further privacy information, please contact WCAT's Freedom of Information Coordinator at the

address or telephone number on the top of this form.

WCAT – 1W (Rev: 12June2013) Page 2 of 2