Notice to Participate Gori coluoel anne
WEESAFEBC| Review Division R0360901

IMPORTANT: To participate in a review you must return this completed form to the Review Division by the due date set out
below.

Worker's name WorkSafeBC claim number

Mark Holand 42647461

Contact information (Please contact the Review Division if this information changes.)
lam the:

(Worker | (JEmployer — Please describe title/position: (Other (please describe)

Last name First name | Employer's name
—

Mailing address

City “T Province | Postal code Email address

Work phone number (include are code} Home phone number gnclude area code} Fax number {include area code)

What pronouns do you use (for the purpose Of future communications with the Review Division)?

(J HertimHis 7] SheltevHers [[] Theyrthem/Theirs (2 zemziriZirs 0 other:

The purpose of this question is to clarify our understanding about the background of Review Division's clients as part of implementing the
calls to action of the Truth and Reconciliation Commission (TRC).

Are you an Indigenous person {includes.a person of Indigenous ancestry; Inuit; Metis, First Nations, status and'non-status)?°~~

ia Yes Oo No

lf you self-identify as an Indigenous person, please indicate if you would {ike to be contacted by an Intake Officer to help you navigate the
review process, These experienced staff members can offer neutral support and make sure that cultural sensitivities are respected.

OD Yes (1 No

Request for review information

| wish to participate in the review of the (please check one):

(Compensation decision (Assessment decision (Prevention decision/order
Date of the decision being reviewed:

March 23, 2026

WorkSafeBC claim or employer number(s):

42647461
lua name: |

Mark Holand
Review number: " ~~ |

RO360901

Due date

You must return the form to the Review Division on or before (day/month/year): July 2, 2026

If we have not received a response by the due date, the review process will proceed without your participation.

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