The Advisor Office (AO) for Alberta Workers’ Compensation can provide advice about the WCB decision you are questioning, and your options for appealing. The AO can formally represent you at all levels of the WCB appeals process – WCB Customer Service, Dispute Resolution and Decision Review Body, and the Appeals Commission.

This form, when signed, allows the AO to gather information about your WCB claim(s) or account. You give the AO permission to represent you and speak with or write to WCB or about your claim(s) or account. Failure to complete all sections of this form may result in service delays.

AN AUTHORIZATION MUST BE COMPLETED FOR EACH EMPLOYER ACCOUNT.

A. Employer Information

Legal Name of Company

WCB Account Number

Industry Code

Industry Classification

Address

Town/City

Province Alberta British Columbia Manitoba Newfoundland and Labrador New Brunswick Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal Code

Phone

Fax Number

Primary Contact

Title

Phone

Email

Secondary Contact Name

Title

Phone

Email

B. Scope of Representation

I authorize the AO to represent me with respect to:

C. Details about the Claim

Worker’s First Name

Worker’s Last Name

Claim Number

Decision Date(s)

D. Authorization to Collect Information from Workers’ Compensation Board

By signing, I authorize the AO to collect information, including personal information, about my account and claim(s) verbally, electronically, in writing, or in person from WCB for reviewing or appealing a WCB decision and providing advisory services. I authorize WCB to disclose personal information to the AO that is necessary for the purpose of providing appeals and advocacy services. This includes, but is not limited to, obtaining a copy of my account and claim files and copies of correspondence sent to me by WCB.

E. Term of Authorization

• This authorization will remain in effect for 3 years from the date signed below, unless you rescind it before. To change your authorization, you must notify the AO at advisoroffice@gov.ab.ca.
• Should you require further assistance on this matter or another matter following the expiry of this authorization, you must submit a new authorization form. We will contact you to update the authorization form about 3 months before it is set to expire.

This form is to be used when an employer wishes to authorize the Advisor Office to act as formal representative with respect to a claim or account matter.

F. Protection of Privacy

The AO collects and manages personal information under the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act (Alberta). The AO will use your personal information for the purpose of reviewing claim(s) within Alberta’s workers’ compensation system. The information will also be used for providing appeals advisory services on your WCB matter.

Your personal information may also be used to contact you to complete a survey. The AO will not use or disclose your personal information for any other purpose without your written consent or, unless required to do so by law. Should you have any questions pertaining to the collection of your personal information, please contact the AO toll-free at 1-866-427-0115, or advisoroffice@gov.ab.ca.

G. Service Commitment

I have read the AO Service Commitment and I acknowledge the terms set out in it.

H. Authorization

I confirm that:

• I am the Primary Account Holder for the Employer;
• I have the authority to sign this form on behalf of the Employer; and
• I agree to the terms set out in this Service Request and Authorization.

Important Note: If any of the above information is not provided or is incomplete, it will cause a delay in proceeding with your file.

How did you learn about the Advisor Office?