Request for a decision review

Note: You have one year from the date of the decision to submit your request for review. Additional information on our collaborative review process is available for workers and employers.

1. Contact the person who made the decision

If you do not understand or agree with a decision, ask for a full explanation.

• For claims: contact your adjudicator or case manager
• For accounts: contact the customer contact representative, auditor, underwriter, etc. You may be asked to provide them additional information that may help them to change the decision.

If you have new information that we may not be aware of, you would provide it in this step. If you still disagree with the decision, please ask to speak to the supervisor.

Would you like to receive assistance from the:

Advisor Office
(for workers and eligible employers) Employer Appeals Consulting
(for employers)

2. Please ensure you have a copy of your file

If you feel you have new information not already on your file, please send this information to your file. Be sure to provide any additional information you feel could impact the decision you disagree with.

3. Request a decision review

To start your request, complete the online form.

Claim number: (for requests from workers or employers about a claim decision)

Account number: (for requests from employers about a WCB account decision)

First name: *

Last name: *

Role/Position: * Employer Employer Representative Worker Worker Representative

Address: *

Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ---------------------------

Phone number (with area code):* ( ) -

Email address: *

I disagree with the decision of Customer Service concerning this claim/account and request the decision be reviewed.

What is the decision you wish to have reviewed? (be as specific as possible): *

Temporary total disability benefits

Medical aid

Wage loss (ELP, TEL, ELS, TPD)

NELP

Re-employment benefits

Other, please specify

What is the date of the letter sent to you that explains the decision?: * Select date

If you have more than one decision letter you wish to have reviewed, enter the dates here:

What are your reasons for requesting a review of this decision? Provide relevant facts from your claim to support your position: *

What results do you want from this review? Be as specific as possible: *

Do you have a representative to act on your behalf? *

Yes No

If yes, Representative name: *

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