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EXT08 (20210401) Page 1 of 6

Effective April 1, 2021

See Practice Guideline #5 – Application to Reconsider a Decision

for more information about completing this form

Reconsideration Application

Please note that you do not need to fill out both Sections 5 and 6 of this form, unless you are applying under both

sections. Only fill out the sections that reflect the reason you are applying for reconsideration.

Section 1: Claim/Account information

Claim/Account #:

Section 2: Decision information (must be completed by all applicants)

I am making application for reconsideration of the following Appeals Commission Decision:

Decision

Number:

Date of

Decision:

Section 3: Applicant contact information

Name of Party Applying

for Reconsideration:

Last Name

Given Name(s)

Address

Street

Apartment, Suite, Unit Number or PO Box #

City/Town

Province

Postal Code

Work Phone

Cell Phone

Fax Number

Messages Only

Email Address

If the contact information changes, you must update the Appeals Commission immediately.

Section 4: 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.

Appeals Commission – Reconsideration Application

Page 2 of 6 EXT08 (20210401)

Effective April 1, 2021

Complete Section 5 if your reconsideration application is based on the submission that new evidence is now available that:

 on reasonable and justifiable grounds could not have been presented previously

 is relevant to the decision; and

 is likely to have had an impact on the decision

Section 5: New evidence application details

 If you are submitting more than one document as new evidence, you must give each document a sequential number

starting at R1, R2, R3, etc.,

 You must complete the following information for each document you are submitting

Document Number:

Document Date:

Author of the Document:

Description of the Document:

____________________________________________________________________________________________________________

Why is this document new evidence? What issues of appeal does the document refer to?

____________________________________________________________________________________________________________

Why did you not submit the document at the initial hearing?

____________________________________________________________________________________________________________

Why is this document relevant to the decision?

____________________________________________________________________________________________________________

How would it change the decision that was made?

____________________________________________________________________________________________________________

Appeals Commission – Reconsideration Application

Page 3 of 6 EXT08 (20210401)

Effective April 1, 2021

Section 5: New evidence application details

 If you are submitting more than one document as new evidence, you must give each document a sequential number

starting at R1, R2, etc.,

 You must complete the following information for each document you are submitting

Document Number:

Document Date:

Author of the Document:

Description of the Document:

____________________________________________________________________________________________________________

Why is this document new evidence? What issues of appeal does the document refer to?

____________________________________________________________________________________________________________

Why didn’t you submit the document at the initial hearing?

____________________________________________________________________________________________________________

Why is this document relevant to the decision?

____________________________________________________________________________________________________________

How would it change the decision that was made?

____________________________________________________________________________________________________________

If you require additional space for your Section 5 submission, please make

additional copies of this page and after completion attach to your application.

Appeals Commission – Reconsideration Application

Page 4 of 6 EXT08 (20210401)

Effective April 1, 2021

Complete Section 6 if your reconsideration application is based on an allegation of a significant defect.

Section 6: A significant defect in the appeal process or content of the decision

What issue of appeal has the defect? Identify the specific paragraph(s) from the decision that demonstrate the defect.

____________________________________________________________________________________________________________

What are the specific ways you believe there was a significant defect in the process or content of the decision? Please

explain the defect.

____________________________________________________________________________________________________________

How do you suggest this defect might be corrected?

____________________________________________________________________________________________________________

If you require additional space for your Section 6 submission, please make

additional copies of this page and after completion attach to your application.

Appeals Commission – Reconsideration Application

Page 5 of 6 EXT08 (20210401)

Effective April 1, 2021

Section 7: Hearing information

I prefer:

☐ a documentary hearing

☐

an in-person hearing

☐ in Edmonton

☐ in Calgary

☐ a teleconference hearing

☐ a video conference hearing

Section 8: Signature

______________________________________

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.

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

Appeals Commission – Reconsideration Application

Page 6 of 6 EXT08 (20210401

Effective April 1, 2021

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

Use Only

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