WORK

BC

Application for Compensation and

Report of Injury or Occupational Disease

If you have any questions, please call our Contact Centre at 604.231.8888 or toll-free at 1.888.967.5377.

Worker first name: Worker last name: PHN: SIN: Claim number:

MARK HOLAND 9128-549-738 730-742-368 42647461

Report setup

Interpreter? Preferred language: WorkSafeBC claim number: User ID: Claim type:

No 42647461 JD20250 Occupational
Disease

Other party information

Are you the injured worker?

Yes

Worker information

Last name:

HOLAND

First name:

MARK

Middle name or initial: Preferred first name:

Date of birth:

Personal health number:

Social insurance number: Customer care number:

Home: (236) 994-3376

September 04, 1978 9128-549-738 730-742-368 93970460601
Occupation: Gender: Dominant hand:
Relief Control Operator Right handed
Marital status: Height: Weight:

Married 69 inches 165 Ibs

Address: City:

UNIT 311 318 AGNES ST NEW WESTMINSTER
Province/state: Postal/zip code: Country:

British Columbia V3L 033 Canada

Phone: Email:

marktholand@gmail.com

Incident information

No

Injury(ies) resulted from a specific incident?

From date:
January 12, 2026

To date:
January 25, 2026

6T

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