Request for Review Application - Workplace Health, Safety and Compensation Review Division

WorkplaceNL Decision Information

Decision(s) Made By:

Date of WorkplaceNL Internal Review decision(s) to be reviewed:*

If possible, please attach a copy of decision:

Accepted file types: jpg, jpeg, pdf, docx, Max. file size: 5 MB.

Worker Information

Claim Number(s):

Claim Number(s):*

Address

City/Town:

Address*

City/Town:*

Province:

Postal Code:

Province:*

Postal Code:*

Telephone:

Cell Phone:

Telephone:*

Cell Phone:

Email:

Dependent's Email:

Accident Employer Information

Company Name:

Firm Number:

Company Name:

Firm Number:*

Address:

City/Town

Address:*

City/Town*

Province:

Postal Code:

Province:*

Postal Code:*

Telephone:

Cell Phone:

Telephone:*

Cell Phone:

Email:

Fax:

Authorization and Consent

The following individual has consent to act as the Authorized Representative for the purposes of the WHSCRD review process

Representative Contact Information

Agency (If applicable):

Address:

City/Town:

Province:

Postal Code:

Telephone:*

Cell Phone:

Email:

Agency:

(If applicable)

Address:

City/Town:

Province:

Postal Code:

Telephone:*

Cell Phone:

Email:

Why do you disagree with this decision?*

(Please explain how WorkplaceNL made an error in applying policy and/or legislation)

What type of benefit are you requesting?*

(Please note - this should be specific to the decision under review. Benefits not referenced in the internal review decision are not able to be reviewed under this application.)

This extension of time is required for the following reason(s):*

(Please provide full details)

Declaration and Authorization

Applicant Name*

Date*

Personal information on this form is collected for the processing of a WHSCRD Request for Review Application and subsequent hearing under the Workplace Health, Safety and Compensation Act and the Access to Information and the Protection of Privacy Act, 2015. I acknowledge that WHSCRD may obtain, view and/or disclose information related to this review to other participating parties for the express purposes of this review. Further, I authorize the representative identified above to act on my behalf for the purposes of this review until otherwise indicated, including providing evidence and making submissions. I understand that it is a serious offence to knowingly provide false information in order to induce particular decisions. Form revised April 2021