FORM: Notice of Appeal – WorkSafeBC prohibited action decision | Workers' Compensation Appeal Tribunal (WCAT)

This form will be your formal notice of appeal. Submit it within 90 days of your WorkSafeBC prohibited action decision. If it’s been more than 90 days, also submit a request for an extension of time.

Appealing a WorkSafeBC decision does not delay it taking effect. If the WorkSafeBC decision makes any orders (such as an order to pay a penalty) then you may request a “stay” (pause) of that order while WCAT is considering your appeal. If you want to apply for a stay you must submit an Application for a Stay to WCAT within 7 days of the date we receive this Notice of Appeal.

It takes about 10 to 15 minutes to complete this form. Make sure you have the following information ready:

The WorkSafeBC prohibited action decision number for the decision you are appealing
The WorkSafeBC employer account number for the employer affected by the prohibited action decision
The contact information for your representative (if you have one)

Questions marked (Required) must be filled out so that WCAT can register your appeal. You don’t need to argue your appeal at this time. Only basic information is required to start your appeal. You can provide more details later.

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.

What would you like to appeal?

Tell us about your WorkSafeBC prohibited action decision.

WorkSafeBC prohibited action complaint number (Required)

WorkSafeBC prohibited action decision date (Required)

Previous grievance(s) (Required)

Has a grievance under a collective agreement been filed regarding this prohibited action decision?

Yes
No
I don’t know

Tell us about yourself

What is your role in the WorkSafeBC prohibited action decision? (Required)

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

WorkSafeBC employer account number

If you know it, please give us the three- to nine-digit WorkSafeBC employer account number (sometimes called a firm file number) of the employer affected by the prohibited action decision. This helps us to identify the correct prohibited action decision.

Employer firm/business name

If you know it, please give us the name of the employer firm/business affected by the prohibited action decision to help us identify the correct WorkSafeBC decision.

WorkSafeBC employer account number (Required)

Please give us your three- to nine-digit WorkSafeBC employer account number (sometimes called a firm file number).

Your firm/business name (Required)

Your union name (Required)

Your name (Required)

First Last

Your Date of Birth or Social Insurance Number

Your pronouns and title

Your pronouns and title will help us to address you respectfully during the appeal process. If you choose “not listed”, a new field will open where you can tell us your pronouns and/or title.

You are free to skip these questions. If there is information about your gender in the WorkSafeBC file(s), we will use that when choosing how to address you.

Your pronouns

They/Them
She/Her
He/Him
Pronouns not listed

Your pronouns (Required)

Please tell us your pronouns.

Your title

Your title (Required)

Please tell us how you would like to be addressed.

How WCAT can send you information

Please note: WCAT Online Services is not available for appeals of Prohibited Action decisions.

Your email address for form confirmation, prohibited action file(s), and videoconference invitations (Required)

WCAT will use this email address to confirm that we have received this form.

WorkSafeBC can also use this address to provide you disclosure, which is a copy of the claim file. Videos, photographs, and audio statements will be delivered by mail on a DVD up to two weeks after the claim file is available online.

WCAT may also send videoconference invitations to this address.

If you are represented, the claim file will be sent to your representative. You can enter your representative’s email address later.

Enter Email Confirm Email

Can WCAT share your email with WorkSafeBC for disclosure?

WorkSafeBC can also use your email address you entered above to provide you disclosure, which is a copy of the claim file. Videos, photographs, and audio statements will be delivered by mail on a DVD up to two weeks after the claim file is available online. If you are represented, the claim file will be sent to your representative.

WCAT can share my email address with WorkSafeBC so they can send me disclosure
I prefer to receive my copy of the claim file by mail

Can WCAT share your email with WorkSafeBC for disclosure?

WorkSafeBC can also use your email address you entered above to provide you disclosure, which is a copy of the claim file. Videos, photographs, and audio statements will be delivered by mail on a DVD up to two weeks after the claim file is available online. If you are represented, the claim file will be sent to your representative.

WCAT can share my email address with WorkSafeBC so they can send me disclosure
I prefer to receive my copy of the claim file by mail

WCAT will only use your email address to send you a confirmation of this form.

Can WCAT send you email related to your prohibited action appeal? (Required)

If you select yes, WCAT will send all letters and decisions about your appeals and applications by email instead of mail. WCAT will also use this address to provide you disclosure, which is a copy of the prohibited action file(s).

Yes, please send me email at the address I entered above
Yes, please send me email a different address. (I will enter it in a new field below)
No, I prefer mail

Your alternate email address for appeal information (Required)

Enter Email Confirm Email

Your mailing address (Required)

Please provide a mailing address even if you have provided an email address above.

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

Your phone number (daytime) (Required)

Your phone number (other)

Your fax number

Your phone number (daytime) (Required)

Your phone number (other)

Your fax number

Are you an Indigenous person (includes a person of Indigenous ancestry: Inuit, Metis, First Nations, non-status, status, and anyone with First Nations ancestry)?

Yes
No
I prefer not to answer

If you self-identify, you can work with a WCAT Navigator to tell your story. These experienced staff members can offer neutral support and make sure that cultural sensitivities are respected. This service is part of implementing the Truth and Reconciliation Commission’s Calls to Action. Learn more about self-identifying as Indigenous.

Reason for appeal

Briefly tell us why the decision is wrong. You will have a chance to provide more information later.

The decision is wrong or should be changed because: (Required)

Change requested from appeal

Briefly tell us about the change you would like to have made to the prohibited action decision. You will have a chance to provide more information later.

This is what I would like to have happen: (Required)

Method of appeal

WCAT will decide how your appeal will proceed. Tell us what your preference is: (Required)

In writing (through written submissions)
Verbally (by oral hearing)

Please tell us why an oral hearing is necessary: (Required)

Oral hearing method (Required)

An oral hearing can be held by videoconference on Microsoft Teams or in person in one of twelve cities in BC. If you select “in person,” you can then tell us your location preference.

By videoconference
In person

Oral hearing location (Required)

If an oral hearing is held, do you need an interpreter?

WCAT provides professional interpreters for oral hearings. Family and friends may not interpret for you.

Yes
No

The language (and dialect) I speak is: (Required)

If an oral hearing is held, will you bring witnesses?

Yes
No
Unsure

List of witnesses

If you are ready, please provide the name of each witness you plan to bring to an oral hearing, if one is held. Use the “plus sign” icon to add another witness. This is just an early list. You will be able to change it later.

First Name	Last Name

Representation

You may appoint a person or an organization (with or without a specific contact) to represent you, or you may represent yourself.

Do you have a representative? (Required)

No, I will be representing myself
Yes, I have a professional representative
Yes, I have a friend/family member representing me

As you are represented, notice of disclosure of the prohibited action file(s) will be sent to your representative at the information you provide below.

Please note that family and friend representatives are not authorized to receive a copy of the prohibited action file(s). It will need to be sent to you instead.

Name of representative's organization/firm (Required)

Representative's name (Required)

First Last

Representative’s pronouns and title

Your representative’s pronouns and title will help us to address them respectfully during the appeal process. If you choose “not listed”, a new field will open where you can tell us your pronouns and/or title.

Representative's pronouns

They/Them
She/Her
He/Him
Pronouns not listed

Representative's pronouns (Required)

Please tell us your representative’s pronouns.

Representative's title

Representative's title (Required)

Please tell us how to address your representative.

Representative's relationship to me (Required)

Representative's email address for disclosure (Required)

Representatives must provide an email address so WorkSafeBC can send them a copy of the prohibited action file(s).

Enter Email Confirm Email

Can WCAT use this email address to send you information about this appeal? (Required)

WCAT Online Services is not available for prohibited action appeals

Yes, please send email to my representative
No, please send appeal information to a different email address
No, my representative prefers correspondence by mail

Representative's email address for appeal information (Required)

Enter Email Confirm Email

Representative's mailing address (Required)

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

Representative's phone number (daytime) (Required)

Representative's phone number (other)

Representative's fax number

Certification and authorization

Is a workers' adviser from the Workers' Advisers Office submitting this form on your behalf?

Operating independently of WorkSafeBC, the Workers’ Advisers Office provides free advice and assistance to workers and their dependants on disagreements they may have with WorkSafeBC decisions.

Yes
No

Is a workers' adviser from the Workers' Advisers Office submitting this form on your behalf?

Operating independently of WorkSafeBC, the Workers’ Advisers Office provides free advice and assistance to workers and their dependants on disagreements they may have with WorkSafeBC decisions.

Yes
No

Adviser's name

First Last

This form must be signed by the appellant or by their authorized representative. If signed by an authorized representative, WCAT requires an authorization form less than 2 years old that is signed by the appellant.

Authorization of Representative (Required)

I will fill out an Authorization of Representative form and submit it online
An Authorization of Representative should be on file with WorkSafeBC
This form authorizes the person/firm named above as my representative (appellant must sign the form below)

Full name of person signing this form (Required)

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

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 my claim file(s) and information 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 314 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 this appeal or the decision(s) being appealed.

Date signed

Representative's email address for form receipt only

If your representative would like to receive an email confirming that WCAT has received this form, enter an email address here.

Enter Email Confirm Email

Name

This field is for validation purposes and should be left unchanged.