Withdrawal of Reconsideration Request

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Withdrawal of Reconsideration Request

Withdrawal of Reconsideration Request

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This information is being collected for the purpose of administering and enforcing the Workers’ Safety and Compensation Act in compliance with the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the board’s privacy officer at 401 Strickland St., Whitehorse, YT, Y1A 5N8 or call 867-667-5645 or 1-800-661-0443.

Are you a Worker or Employer

Worker Employer

I confirm that I am withdrawing the following request for reconsideration of a WSCB decision, that has been filed by me or on my behalf

Date of applicable WSCB decision

Date of request for reconsideration

WSCB claim number if applicable

I understand that if I/we wish to refile a request for reconsideration of the above WSCB decision, a new request for reconsideration must be filed within the applicable time limits set out in the Workers’ Safety and Compensation Act, SY 2021, c. 11.

I acknowledge that electronic communication has inherent security risks, as do all forms of communication. Notwithstanding the inherent risks of electronic communication, I consent to the use of electronic methods to transmit and receive information, including confidential and personal information between the board and myself. This consent will remain in effect until written notice to revoke this authorization has been received by the board.

Name of person completing this form

Date