NOTICE OF SECTION 29 APPLICATION
Applicant's Name	Representative & Firm Name
Telephone number

Fax number	Supreme Court Reference Number:
Street Address

City, Province

Postal Code
Has a workers' compensation claim been filed as a result of the accident/injury?	Check One

YES

NO	If yes, please indicate the relevant claim number(s):

Respondents, Other Potential Participants & Representatives (attach additional sheets if necessary)
Name	Representative & Firm Name
Telephone Number	Fax Number
Street Address

City, Province

Postal Code
Name	Representative & Firm Name
Telephone Number	Fax Number
Street Address

City, Province

Postal Code
Name	Representative & Firm Name
Telephone Number	Fax Number
Street Address

City, Province

Postal Code

Name	Representative & Firm Name
Telephone Number	Fax Number
Street Address

City, Province

Postal Code
FACTS & ISSUES
Date of Personal Injury
Location of Accident
Other person(s) involved

Description of how injury occurred

Residency of participants

Factual and legal issues on this application (including Policy, Legislation or Regulations)

What questions do you want the Tribunal to decide?

Has a trial date been set?	Check One YES NO Date if set:
MODE OF HEARING REQUESTEDED
Mode of Hearing Requested	Check One	Oral Hearing Written Submission

Note: If you do not indicate your preference, the Tribunal will assume that you wish to proceed by written submission.

Proceeding by written submission means that you will not appear before the Tribunal and the Appeal Commissioner(s) will decide the appeal after reviewing the WCB claim file(s) and any written submissions/evidence which may be provided by the participants. An oral hearing means that you will appear before an Appeal Commissioner(s) to present oral evidence and submissions. Oral hearings will be held in various centres throughout the Province.
Reasons for Requesting Mode of Hearing

Date	Signature of Applicant or Representative