NOTICE OF APPEAL FROM REVIEW DIVISION Compensation Decision

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150 - 4600 Jacombs Road, Richmond, British Columbia V6V 3B1
Telephone: (604) 664-7800 Toll-Free: 1-800-663-2782
Fax: (604) 664-7898 Website: www.wcat.bc.ca

NOTICE OF APPEAL
FROM REVIEW DIVISION:

Compensation Decision

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 (www.wcat.bc.ca) under the Forms tab, or call us and we will send you the form.

1. WORKER CLAIM INFORMATION

Worker Last Name * help

Worker First Name * help

Mr. or Ms. *

WorkSafeBC Claim Number(s) * help

WorkSafeBC Customer Care # (if known) help

2. INFORMATION ABOUT YOU (APPELLANT)

To keep your appeal active you must tell us about changes in this information.

I am the worker help

Worker BC Care Card # help

I am the employer help

Employer Firm Name

Job Title of Employer Contact named below

I am the dependant of a deceased worker help

My Last Name *

My First Name *

Mr. or Ms. *

Mailing Address * help

City/Town * help

Province * help

Postal Code * help

Telephone (daytime) *

( )

Telephone (other) help

( )

Fax Number help

( )

3. REVIEW DECISIONS

A Review Division decision may decide more than one request for review. List below each Review Reference # you are appealing.

Review Division Reference #(s): * help

1) R

2) R

3) R

4) R

5) R

Date of Review Decision you are appealing * help

Please attach a copy of the first page
of the Review Division Decision.

Copy is attached.

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: * help

(Please attach additional page(s) if necessary.)

WCAT - 1 (Rev: 06/09)

5. RESULT/BENEFIT 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: * help

(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 * help

7. METHOD OF APPEAL

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

in writing (through written submissions) help

verbally (at an oral hearing) help

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

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

Yes â€“ The language I speak is

Dialect

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

No Yes

8. REPRESENTATION

You may appoint one person or an organization to represent you or choose to represent yourself. Please indicate your choice below.

Will you be representing yourself? * help

Yes (go to next section) No (please choose one of the following):

I want to appoint an organization as my representative.

Name of Organization

I want to appoint one person to represent me.

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

Last Name of Representative/Organization Contact

First Name of Representative/Organization Contact

Mr.orMs.

Mailing Address help

City/Town

Province

Postal Code help

Telephone (Daytime) * help

( )

Telephone (Other) help

( )

Fax Number help

( )

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 (www.wcat.bc.ca). 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.

Signature of appellant or authorized representative

Date Signed (YYYY-MM-DD)

10. FORM CHECK-LIST

Number of additional pages attached?
Did you provide Worker Last Name and WorkSafeBC Claim Number on 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 www.wcat.bc.ca 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 of an appeal to WCAT 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 provided above.

4, continued:

5, continued:

7, continued:

Worker Last Name:

WorkSafeBC Claim Number(s):

WCAT - 1 (Rev: 06/09)

IMPORTANT NOTICE!

1. WORKER CLAIM INFORMATION

2. INFORMATION ABOUT YOU (APPELLANT)

To keep your appeal active you must tell us about changes in this information.

3. REVIEW DECISIONS

A Review Division decision may decide more than one request for review. List below each Review Reference # you are appealing.

4. REASON FOR APPEAL

Provide a brief answer for each Review Reference # you wish to appeal.

5. RESULT/BENEFIT REQUESTED FROM APPEAL

Provide a brief answer for each Review Reference # you wish to appeal.

6. WorkSafeBC DISCLOSURE

Your copy of the WorkSafeBC file will be sent in CD format unless you request a paper copy.

7. METHOD OF APPEAL

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

8. REPRESENTATION

You may appoint one person or an organization to represent you or choose to represent yourself. Please indicate your choice below.

9. CERTIFICATION AND AUTHORIZATION

10. FORM CHECK-LIST

4, continued:

5, continued:

7, continued: