Fillable Notice of Appeal See Practice Guideline #1 Filing (Augustana University College)

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Notice of Appeal See Practice Guideline #1 Filing (Augustana University College)

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Page 1 of 4 EXT02 (20210401)
Effective April 1, 2021
Notice of Appeal
See Practice Guideline #1 – Filing an Appeal
for more information about completing this form
Section 1: Appellant contact information
I am a:
☐
Worker
☐
Employer
Appellant Last Name or Company Name
Given Name(s)
Street Apartment, Suite, Unit Number or PO Box #
City/Town Province Postal Code
Home Phone Work Phone Cell Phone Fax Number Messages Only
Email Address
If you are an employer,
please fill in the boxes
on the right:
Name of a person in the company who is in charge of the appeal
Contact’s Phone
If the contact information changes, you must update the Appeals Commission immediately.
Section 2: Representation
☐ I Have a Representative ☐ I Plan to Get a Representative ☐ I Will Represent Myself
If you have a representative, you must submit a separate Notice of Representation form at the same
time you submit this form. If you plan to get a representative, you must submit the Notice of
Representation once you have a representative. This gives us the authorization to work with your
representative.
Section 3: What are you appealing?
I appeal the following Dispute Resolution and Decision Review Body (DRDRB) decision(s):
Claim/Account # Date of decision
(DD/MM/YYYY)
Attach a copy of the decision
☐ Copy Attached
☐ Copy Attached
☐ Copy Attached
☐ Copy Attached
Appeals Commission - Notice of Appeal
Page 2 of 4 EXT02 (20210401)
Effective April 1, 2021
Section 4: What are the issues?
Issue 1:
Page # of decision
relating to issue
Issue 2:
Page # of decision
relating to issue
Issue 3:
Page # of decision
relating to issue
Issue 4:
Page # of decision
relating to issue
Issue 5:
Page # of decision
relating to issue
Issue 6:
Page # of decision
relating to issue
Issue 7:
Page # of decision
relating to issue
If there are more issues, please copy this page and continue.
Appeals Commission - Notice of Appeal
Page 3 of 4 EXT02 (20210401)
Effective April 1, 2021
Do you need an interpreter?
Yes
☐ No ☐
Language and Dialect of the Interpreter: ___________________________________________
Examples of accommodations can include but are not limited to the need for a chair fitted with a back brace, the support of a
service animal, and/or extra breaks during the hearing. If you need any accommodations, please tell us in the space provided
below, and you will be contacted to discuss any reasonable accommodation the Appeals Commission can offer.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Section 6: Type of hearing
☐ A documents only hearing
☐ A teleconference hearing
☐ An in-person hearing in Edmonton
☐ A video conference hearing
Section 7: Are you ready to proceed?
☐ I am ready to have a hearing date scheduled ☐ I am not ready to have a hearing date scheduled
Section 8: Additional information
Please use this section to provide any additional information you feel the Appeals Commission requires in processing your Notice
of Appeal.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
____________________________________
___________________________________________________________________
____________________________________
___________________________________________________________________
Section 9: What am I signing?
By m
y signature, I appeal the issue(s) in the decision(s) or determination described above.
____________________________________________________________
Signature
__________________________________________________________
Date (DD/MM/YYYY)
Print the name of the person signing: ____________________________________________
A representative may only sign this form if they are authorized as a representative in this appeal. You must submit a
separate Notice of Representation to authorize a representative.
☐ An in
-person hearing in Calgary
Appeals Commission - Notice of Appeal
Page 4 of 4 EXT02 (20210401)
Effective April 1, 2021
If you have not received an acknowledgement of your appeal from the Appeals Commission within one month of filing, contact
us.
You can file this form by:
• submitting it online through our website;
• e-mail addressed to AC.AppealsCommission@gov.ab.ca;
• mail;
• fax; or
• courier or personal delivery to one of our two offices.
Edmonton
Appeals Commission for Alberta Workers’ Compensation
1100,10405 Jasper Avenue
Edmonton AB T5J 3N4
Tel: 780-412-8700
Fax: 780-412-8701
Calgary
Appeals Commission for Alberta Workers’ Compensation
2300, 801 – 6
th
Avenue SW
Calgary AB T2P 3W2
Tel: 403-508-8800
Fax: 403-508-8822
You can view our web site at: www.appealscommission.ab.ca
Collection, Use and Disclosure of Personal Information:
• The personal information that you are being asked to provide is collected under the authority of section 33(c), and
managed in accordance with the Freedom of Information and Protection of Privacy Act.
• The information will be used for the purpose of processing your request for a hearing with the Appeals Commission
for Alberta Workers’ Compensation.
• It is important that every party to the appeal knows the case that is to be heard and has an opportunity to respond.
• Because of this, we share all documents related to the appeal with all other parties to the appeal and the Workers’
Compensation Board.
• The information you provide may also be used for quality assurance and training purposes.
• If you have any questions regarding the collection, use or disclosure of your personal information, please contact the
Appeals Commission.
For Appeals Commission
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Notice of Appeal See Practice Guideline 1 Filing (Augustana University College)

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Completed 15 December 2021

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