APPLICATION FOR RECONSIDERATION OF A WCAT 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

APPLICATION FOR
RECONSIDERATION OF A WCAT DECISION

*Important - Read the Post-Decision Guide before completing this form. Use this form to apply to WCAT Tribunal Counsel Office for reconsideration of a WCAT decision. WCAT decisions are "final and conclusive" but we can reconsider our decisions on two limited grounds: new evidence not previously available or discovered; and a jurisdictional defect (error). Complete a separate application form for each WCAT decision you want us to reconsider. There is no time limit for applying for reconsideration. You may apply for reconsideration on each ground once only.

1. INFORMATION ABOUT THE DECISION YOU WANT WCAT TO RECONSIDER

WCAT Decision Number * help

Date of WCAT Decision * help

WCAT Appeal No.(s) * help

WorkSafeBC Claim Number(s) (if applicable) help

2. INFORMATION ABOUT YOU (APPELLANT)

You must tell us about changes in this information.

I am the worker help

I am the employer help

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

WCAT - 65 (Rev: 06/09) Page 1 of 3

Worker Last Name(if applicable)		WorkSafeBC Claim Number(if applicable)
Date of WCAT Decision:		WCAT Decision Number(if applicable)
Employer/Firm Name(if applicable)		WCAT No.(s)

4. REASONS FOR RECONSIDERATION

You must explain the specific grounds for reconsideration. Please attach additional pages(s) if necessary.

A. Jurisdictional Defect (Error) (if applicable)
The decision contains the following jurisdictional error(s). The Post-Decision Guide gives examples of jurisdictional
errors. help

i) There was a jurisdictional error because:

The procedure at WCAT was unfair because:

B. New Evidence Not Previously Available (if applicable)
For each piece of new evidence, complete either (i) or (ii), and complete (iii). help

I have attached the new evidence

i) Did not exist - I have the following new evidence that did not exist before my WCAT decision:

ii) Existed but not found - The following new evidence did exist before my WCAT decision but I did not submit it to WCAT because I did not know about it and I could not have found it if I had tried. (List the evidence and explain why you were not able to find it.)

iii) New Evidence Substantial and Material - For each piece of new evidence, explain why the new evidence is substantial to the decision (has weight and supports a different conclusion) and how it is material (relevant) to the decision.

The new evidence is substantial because:

The new evidence is material because:

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. I understand that WCAT must have my current address to keep my reconsideration application active. I authorize my representative named above to act on my behalf in this reconsideration. For workers: I authorize disclosure of my claim file(s) and information relating to this reconsideration application to WCAT, my representative, and other parties to this reconsideration for the purposes of this reconsideration 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 reconsideration application.

Signature of appellant or authorized representative

Date Signed (YYYY/MM/DD)

WCAT - 65 (Rev: 06/09) Page 2 of 3

Worker Last Name(if applicable)		WorkSafeBC Claim Number(if applicable)
Date of WCAT Decision:		WCAT Decision Number(if applicable)
Employer/Firm Name(if applicable)		WCAT No.(s)

6. FORM CHECK-LIST

Number of additional pages attached? Did you attach any additional documentary evidence? (if applicable)
Did you answer all questions? Call us if you need help filling out this form.
Have you signed in Box 5 above?
Did you keep a copy of your fax confirmation sheet if you are faxing this application?

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.

IMPORTANT NOTICE!

1. INFORMATION ABOUT THE DECISION YOU WANT WCAT TO RECONSIDER

2. INFORMATION ABOUT YOU (APPELLANT)

You must tell us about changes in this information.

3. REPRESENTATION

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

4. REASONS FOR RECONSIDERATION

You must explain the specific grounds for reconsideration. Please attach additional pages(s) if necessary.

5. CERTIFICATION AND AUTHORIZATION

6. FORM CHECK-LIST

4a, continued:

4b, continued:

4c, continued:

4d, continued:

4e, continued:

4f, continued: