SUBMISSIONS
RO360901
WORKING TO MAKE A DIFFERENCE REVIEW DIVISION

Personal information on-this form is collected for the purposes of administerin
Compensation Act and the Freedom of Information and Protection of Privacy
contact WorkSafeBC's Freedom of Information Coordinatar at PO Box 2310

Ig a worker's compensation claim by WorkSafeBC in accordance with the Workers
Act. For further information about the collection of Rersonal information, please
Sin Terminal, Vancouver BC, V6B ‘SWS, or telephone 604 279-8171

§3M5-P

If you have questions, please call 604-214-5411 or 1-888-922-8804

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