| work Eat 1 Memo
(continued)

WORKING TO MAKE A DIFFERENCE

Worker last name First name Middle initial WorkSafeBC claim number

HOLAND 42647461

Ms Jaylin Cassady

Sr Adjudicator

Claims Intake & Adjudication Services

Personal information on this form is collected for the purposes of administering a worker's compensation claim by WorkSafeBC in accordance with the Workers Compensation Act

and the Freedom of Information and Protection of Privacy Act. For further information about the collection of personal information, please contact WorkSafeBC’s Freedom of
Information Coordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or telephone 604 279-8171.

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