Worker Appeal of Claims Decision

Should you have any questions when completing this form, please call the Assistant Scheduling Co-ordinator at (204) 925-6116 or toll free at 1 (855) 925-6110.

Where Can I Get Help

Fields marked with (*) are required.

Section A: Worker Information

Worker Name:

Claim Number:

Address:

City/Town:

Province:

Postal Code:

Phone (home):

Phone (work):

E-Mail Address:

Section B: Employer Information

Employer (at time of injury):

Section C: Representative Information

Representative Name (if applicable):

Address:

City/Town:

Postal Code:

Phone:

Email:

If you will be represented on your appeal, you must provide a separate signed and dated authorization naming your representative.

Section D: Language Interpretation

Any required interpretation services will be arranged by the Appeal Commission.

Please check here if you require the services of an interpreter

Please indicate language:

Section E: Appeal Information

I wish to appeal the decision dated (dd/mm/yyyy):

The decision(s) I wish to appeal is(are):

Maximum length: 800 characters

I believe this decision of the WCB Review Office should be overturned for the following reasons:

Maximum length: 800 characters

Section F: Appeal Method

Please indicate by which method you wish to pursue your appeal (select one)Videoconference (definition)
In Office - 330 St. Mary Ave (definition)
Teleconference (definition)
File Review (definition)

If you are requesting a hearing, please state the reasons why you consider that a hearing is necessary:

Maximum length: 800 characters

The Chief Appeal Commissioner has the final authority to determine the method of appeal.

Signature: (name indicates online form completion)

Date: (date of online submission)

Once the request has been sent, you will also receive a copy of your application via email. Please save or print the PDF for your records.