Please complete as much of the form below as possible.

Your Name and phone number (required)

What is the specific issue you need an advocate to assist with (required)?

WCB AB Claim number or numbers (optional):

Date of Accident:

List/approximate dates of surgeries related to your accident:

List/approximate dates of surgeries not related to your accident (optional):

Injuries Accepted by WCB:

Injuries Denied by WCB:

Pre-accident Annual Salary and position:

Type of monthly wage benefit currently being paid by WCB, and the monthly amount:

What are your current work restrictions?

If WCB has estimated your earnings, what position did they choose?

List any other current sources of monthly income support:

If you are currently working, describe your job duties:

Are you currently receiving any allowances from WCB, other than your wage replacement

Please list issues you would like us to appeal on your behalf:

Other information you would like us to consider:

Do you already have an appeals advisor or any upcoming hearings?

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