FORM: Authorize a representative | Workers' Compensation Appeal Tribunal (WCAT)

Only use this form if you want to assign someone to act as your representative. You are not required to have one. This form authorizes the Workers’ Compensation Appeal Tribunal (WCAT) and WorkSafeBC (including the Review Division), to give confidential information about you or your business to your representative. It takes about 5 to 10 minutes to complete.

Questions marked with the * are required for WCAT to complete the authorization.

Collection and use of personal information: 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. Contact the Freedom of Information Coordinator at WCAT if you have questions.

Appeal information

Please give us information about the appeal you have started as an appellant or the appeal to which you have been invited to participate as a respondent.

WCAT appeal number (if known)

Review Division decision number, WorkSafeBC claim number, or WorkSafeBC prohibited action number

If you don't have an appeal number yet, give us the number for the decision you are appealing.

Tell us about yourself

To keep your appeal active (or to continue participating in an appeal), you must tell us if this information changes.

What is your role in the appeal, Review Division decision, or WorkSafeBC decision?*

I am the worker
I am the employer
I am the dependant of a deceased worker

Your name*

First Last

Your pronouns

They/Them/Theirs
She/Her/Hers
He/Him/His

Your title/position

Business/firm name*

WorkSafeBC employer account number*

This is the number for your business/firm as registered with WorkSafeBC.

Your mailing address*

Street address Address line 2 City Province / State / Region Postal / Zip code Country

Your phone number (daytime)*

Your phone number (other)

Your fax number

Your phone number (daytime)*

Your phone number (other)

Your fax number

Representation

You may appoint an organization (with or without a specific contact) or an individual (not affiliated with an organization) to represent you.

What kind of representative do you have?*

I have a professional representative
I have a friend/family member representing me

Name of representative's organization/firm*

Representative's relationship to you*

Name*

First Last

Your representative's pronouns

Can WCAT send emails to your representative about appeals and applications they are participating in?*

Yes, please send email to my representative
No, my representative prefers correspondence by mail

Representative's email address for correspondence*

Enter email Confirm email

Representative's mailing address*

Street address Address line 2 City Province / State / Region Postal / Zip code Country

Representative's phone number (daytime)*

Representative's phone number (other)

Representative's fax number

Representative's phone number (daytime)*

Representative's phone number (other)

Representative's fax number

Scope of representation

You can choose in which workers' compensation matters your representative is authorized to act on your behalf. Check all that apply.

I authorize my representative to represent me with respect to the following workers' compensation matters, including any reviews or appeals that may arise:*

all compensation claim matters
all assessment matters, including authority to settle such matters
all prohibited action matters
all relief of cost matters
all occupational health and safety matters
certification to court (section 311) matters
only the following matters (please provide claim number or other details)

Specific matters for which my representative can represent me*

Please provide claim numbers or other identifying details

Hidden

If your representative is authorized to represent you for compensation claim matters, they will receive a copy of the claim file disclosure on your behalf. WorkSafeBC sends a notification by email when the claim file disclosure is ready to be downloaded. Representatives must provide an email address for claim file disclosures. WCAT will provide this email address to WorkSafeBC. For more information, please see the WorkSafeBC website or call them at their Claims Call Centre at 1.888.967.5377 or 604.231.8888.

Representative's email address for disclosure download notification*

Enter email Confirm email

Certification

You, not your representative, must sign this form.

Full name of person signing this form*

Signature*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the following:

I consent to WCAT or WorkSafeBC disclosing to my representative the contents of any WorkSafeBC file(s) or related information for which I am eligible to receive disclosure, and any other information related to this appeal. I authorize my representative to act on my behalf before WCAT and WorkSafeBC, including the Review Division, with respect to those files. This authorization form replaces any previous authorization(s) I have submitted to WCAT or WorkSafeBC for the same scope of representation identified above. If I cancel this authorization, I understand that I must notify WCAT and WorkSafeBC departments handling my outstanding matters.

For individuals: This authorization shall remain in effect for two years from the date of signing, unless I cancel it in writing, or until my death, whichever is earlier.
For employers: This authorization shall remain in effect for two years from the date of signing, or until I cancel it in writing, or the business is no longer active with WorkSafeBC, whichever is earliest.

Date of authorization

Email address for form receipt only

Enter an email address here if you would like to receive confirmation that WCAT received your form. WCAT will send you a copy of the completed form by mail or email (depending on your preferences as shown on the notice of appeal or participation form).

Enter email Confirm email

Representative's email address for form receipt only

Enter an email address here if you would like your representative to receive email confirmation that WCAT received this form. WCAT will also send your representative a copy of the completed form by mail.

Enter email Confirm email