EXTENSION OF TIME TO APPEAL APPLICATION: Review Division 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: www.wcat.bc.ca

EXTENSION OF TIME TO
APPEAL APPLICATION:

Review Division Decision

Important: You must complete this form and return it to WCAT if you are filing an appeal more than 30 days after the date of the Review Division decision. You must also send in your completed Notice of Appeal. You can find the Notice of Appeal form on our website at www.wcat.bc.ca or call us and we will send you the form.

1. WorkSafeBC FILE INFORMATION

Worker Last Name (if applicable) help

Worker First Name (if applicable) help

Mr.orMs.

WorkSafeBC Claim Number(s) (if applicable) help

Date of Review Decision(s) * help

Worker Customer Care # (if applicable) help

Review Division Reference #(s): * help

1) R

2) R

3) R

4) R

5) R

WorkSafeBC File/Firm #(s) (if applicable) help

Administrative Penalty Order/Inspection Report number(s) (if applicable) help

2. INFORMATION ABOUT YOU (APPELLANT)

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

I am the employer help

I am the worker help

I am the owner help

I am a member of a deceased worker's
family help

I am the union help

I am the supplier help

I am other: help

Name of your Organization (if applicable)

Job Title of Contact Person named below (if applicable)

My Last Name *

My First Name *

Mr.orMs.*

Mailing Address * help

City/Town * help

Province * help

Postal Code * help

Telephone (daytime) *

( )

Telephone (other) help

( )

Fax Number help

( )

3. EXPLAIN WHY YOU DID NOT APPEAL IN TIME

Please attach additional pages(s) if necessary.

A: These are the special circumstances that prevented me from filing my notice of appeal during the 30 days after the date of the Review Division decision: *

WCAT - 15a (Rev: 07/09)

B: If this appeal is not allowed to proceed, the following injustice would result: *

C: My appeal was further delayed beyond the 30 day time limit for appealing because: *

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

4. PROVIDING FURTHER DOCUMENTARY EVIDENCE

If applicable, attach information that supports your explanation of why your appeal was late. Depending on the circumstances of your application, such further evidence might include such things as:
- postmarked envelope or facsimile (fax) confirmation sheet
- proof of travel documents
- doctor's note or report, or other evidence to prove you were unable to appeal because of medical reasons relating to you or a close family member
- signed statement from witness
- significant new evidence about the appeal that did not exist, or was unavailable, when the time to appeal expired

The following documents are attached:

5. 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.

Signature of appellant or authorized representative

Date Signed (YYYY/MM/DD)

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.

6. FORM CHECK-LIST

Number of additional pages attached?
Did you answer all of the questions? Call us if you need help in filling out this form.
Have you signed in Box 5 above?
Did you attach any additional documentary evidence discussed in section 4 of the form? (Please note: Do not delay in
filing this form if you do not have all of your evidence ready. You will have a further opportunity to provide written
submissions and documentary evidence at a later date.)
Did you keep a copy of your fax confirmation sheet if you are faxing in this application?
Did you send in your completed Notice of Appeal (found at www.wcat.bc.ca or call us for one)?

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.

3a, continued:

3b, continued:

3c, continued:

Worker Last Name (if applicable):	WorkSafeBC Claim Number(s) (if applicable):
Employer/Firm Name (if applicable):	File/Firm #(s) (if applicable):