Please complete as much of the form below as possible.

Your Name (required)

Your Email (required)

Subject

Phone:

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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