Online Form Submission

Ready To Continue
Disclosure Agreement
Who Is Completing
Step
Contact & Claim Information
Step
Representation Options
Step
Appointing a Representative
Step
Representation
Step
Application for Interim Relief
Step
Addtional Information
Step
Hearing Details
Step
Signature and Consent

Application for Interim Relief

ATTENTION: Once you start to complete the Application for Interim Relief application, you will NOT be able to save the information and come back to submit it later. It will not save or be submitted until you click the SUBMIT button.

Please see Practice Guideline #7 – Requesting Interim Relief for information that will help you complete your application.

Please make sure you have the items below before starting :

an email address; and
The Notice of Representation form if you have a representative, in either JPEG or PDF format.
Note: The form must be signed and dated by the person being represented within two(2) years of being submitted to the Appeals Commission.

Are you ready to continue?

Are you a worker or employer applying for Interim Relief?

Interim Relief for Worker's Information Interim Relief for Employer's Information

Last Name:

First Name:

Name of Contact:

Contact Phone:

Address

Street:

Apartment/Unit#:

City/Town:

Province:

Postal Code:

Email Address:

Home Phone:

Cell Phone:

Work Phone:

Fax Number:

Alternate Phone:

Optional

Personal Pronouns:

He/Him

She/Her

They/Them

Other

Name Pronunciation:

Information about your application

Claim Number(s):

Date of DRDRB decision being appealed:

Did you receive interim relief from the DRDRB regarding the decision appealed?

Yes

Representation Options

If you have a representative to assist you with your application for interim relief, 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.

Appointing a Representative

You have the option of representing yourself or finding someone to help with an appeal to the Appeals Commission.

A representative is someone who is authorized, in writing, to act on your behalf (preparing your appeal and making arguments during your hearing).

You will need to provide your representative with written permission to get a copy of your file and act as your representative.

Notice of Representation form:

The Notice of Representation form gives us permission to discuss your appeal with your representative.

After you have a chosen a representative, you need to sign a Notice of Representation form and send it to the Appeals Commission.

Please submit a complete Notice of Representation form.

The form must be signed by the person who is being represented.
The date on the form must be no more than 2 years earlier than the date the form is submitted.

Representative’s Information

Representative's Email Address:

Please complete the Notice of Representation form. This form must then be signed and dated before uploading. The form must be signed and dated by the person being represented within two (2) years of being submitted to the Appeals Commission.

Notice of Representation:

Upload the Notice of Representation form in either PDF or JPEG format.

Application for Interim Relief

NOTE: Even if you receive interim relief from the DRDRB, you must answer all of the questions that follow.

Does the workeremployer have an arguable case in the appeal of the DRDRB decision? (Arguable case is a case that presents sufficiently detailed facts, identifies legal or factual issues that are plausible and which, if accepted by the decision maker, could substantially affect the decision in the case.) Please provide reasons.

Does the decision under review or appeal affect the entitlement to current wage loss benefits, and the sum in question is greater than $500? Does the decision under review or appeal impact assessed premiums by more than $500? Please provide documents that show the decision being appealed to the Appeals Commission may impact your assessed premiums by more than $500. These documents can include financial statements, a letter from a bookkeeper, a letter from an accountant, or anything else you think is relevant.

Does the employer demonstrate that the waiting time to have the matter resolved will place the employer in significant financial hardship such as the inability to continue operations, or the employer being forced to lay off a significant portion of its workforce? Please provide documents to support your answer, such as:

Documents that show you will not be able to continue operating while waiting for the Appeals Commission’s decision.
Documents that show you will have to lay off a significant number of employees while waiting for the Appeals Commission’s decision.

These documents can include financial statements, a letter from a bookkeeper, a letter from an accountant, or anything else you think is relevant.

Is the worker, spouse or adult interdependent partner ineligible for any other financial support? Please include documents to support your answer. These can include documents that show you, your spouse or partner are not able to get financial support, like money or benefits, from anywhere else. For example, a document from a government agency or organization which provides money or other benefits to people, like Employment Insurance, Assured Income for the Severely Handicapped or Income Support.

Without interim relief, would the worker and his/her family be placed in necessitous circumstances such as probable inability to afford basic necessities of life such as food, clothing and shelter, or face probable forfeiture or seizure of assets (for example, the family home)? Please include documents to support your answer.
These documents can include:

Financial records such as bank and credit card statements.
Documents showing information about mortgage, rent or lease payments and about your ability to make the payments.
A monthly income and expense statement. This includes a list of how much money you receive each month and from where. It also includes a list of how much money you spend each month and what you spend it on.

Additional Information

Please use this section to attach any documents and any additional information you feel the Appeals Commission needs to process your application for interim relief referred to in Step 3 of this application.

Hearing Information

Interim Relief applications are heard on a documentary basis so that we can make a decision as soon as possible.

Signature and Consent

By my signature, I apply for interim relief. I also consent to the collection, use and disclosure of my personal information provided in this form, and the disclosure of my personal information related to the application for interim relief, to the WCB.

Sign inside the box using your mouse or touch screen.

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.

Documents Submitted Electronically

Our email server automatically records the date and time that you submit electronic documents. This is the time and date that we mark these documents as ‘received’.