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

Declaration

The statements below have been read to the worker, and the worker has verbally acknowledged that they understood:

-This information is collected, used, and disclosed under authority of the Workers Compensation Act and the Freedom of Information
and Protection of Privacy Act.

-WorkSafeBC and the Workers Compensation Appeal Tribunal have the right to view or obtain a copy of records pertaining to

examination, treatment, history, and employment from any source, including records of physicians, qualified practitioners, medical
insurers, hospitals, and employers.

-WorkSafeBC may obtain and share the information from your claim with your employer for the purposes of appeal, or share such
information with others in accordance with the law.

-If you have any privacy-related questions or concerns, please contact the Freedom of Information and Protection of Privacy Office at
604.279.8171.

The information on this application has been reviewed with and certified as true by the worker.

Yes _X_ No.

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