SAFE BC| Notice to Participate

Review Division
R0360901

Worker's:name " ° ~ WorkSafeBC claim number
Mark Holand 42647461

New information

Have you attached any new information that was not considered when the decision was originally made?

OYes [No

Will you be sending in new information that was not considered when the decision was originally made?

ClYes [JNo

Disclosure for review (copy of WorkSafeBC file)

You will receive an email notification when the WorkSafeBC file is available online for downloading from worksafebc.com upon
receipt of your "Notice to Participate” form. If you have a representative, the notification will be sent to the representative's

email address. Videos, photographs, and audio statements will be delivered by Canada Post on a DVD up to two weeks after
your claim file is available online.

Please check (~) the box if you are a worker without email access.

L] No access to email Hf you select this box, your claim fite will be delivered by Canada Post.

Representation (Please contact the Review Division if this information changes.)

Please check (“)one

(]! will represent myself in the review process [il have a represent who will handle t

Representative's name

Name of representative's organization

Represeniative's mailing address-———— cee a eeEceme mate

City Province | Postal code —

Representative's phone number (include area code) Representative's fax number (include area code)

Representative's email address

Authorization

“I wish to participate in this review. | acknowledge that the Board may disclose information regarding this file for purposes of review, or
may disclose such information to others in accordance with the law, including the Freedom of Information and Protection of Privacy Act.
Further, and where applicable, | authorize the representative identified above to act on my behalf for the purposes of this review.”

Participant's name (please print) | Participant's signature Date signed (yyyy-mm-da)
Please send this form to the Review Division Fax Mail
Paget via mail orfax— phone: 604 214-5411 604 232-7747 WorkSafeBC
n .
° Toll Free in BC: 1 888 922-8804 ‘Toll-free 1.855.433.9728 PO Box 2071 Stn Terminal
yaww.worksafebc.com Vancouver BC V6B 3S3

WorkSafeBC collects information on this form for the purposes of administering and enforcing the Workers Compensation Act. That Act, along
with the Freedom of Information and Protection of Privacy Act, constitutes the authority to collect such information. To learn more about the

callection of personal information, contact WorkSafeBC’s freedom of information coordinator at PO Box 2310 Stn Terminal, Vancouver BC,
V6B 3W5, or call 604.279.8171.

63M2 {R22/04) Page 2 of 2

000270