NOTICE OF APPEAL FROM REVIEW DIVISION Non-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: www.wcat.bc.ca

NOTICE OF APPEAL
FROM REVIEW DIVISION

Non-Compensation Decision (Occupational Health & Safety, Assessment, Other)

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.

Appealing a WorkSafeBC decision does not delay its implementation. A "stay" is when we order WorkSafeBC to delay its implementation of a decision (such as an order that you pay a penalty) while we are considering the appeal. If you want to apply for a stay you must file an Application for a Stay with WCAT within 7 days of the date we received this Notice of Appeal. You can find this form on our website at (www.wcat.bc.ca) or call us and we will send you the form.

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 the WorkSafeBC file(s) and information from any source 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.

10. FORM CHECK-LIST

Number of additional pages attached?
Did you provide Employer/Firm name and File/Firm number(s) on the top of this page?
Did you attach a copy of the first page of the 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 attach a completed Application for a Stay form if you want to apply for a stay (found at www.wcat.bc.ca or call us
for one)?

IMPORTANT NOTICE!
	WCAT does not retain any information you enter on-line. Please have a printer available so you can print the form, otherwise the information will be lost.
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*	Denotes required Information.
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IMPORTANT NOTICE!

1. WorkSafeBC FILE 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. WORKPLACE POSTING REQUIREMENT

Proceed to question 7 if this is not an administrative penalty appeal (there is no posting requirement for other types of appeals).

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: