CONTACT REQUEST FORM

Gail Cumming Advocate

WORKERS COMPENSATION EXPERT CONSULTATION

REQUEST FORM FOR CONSULTATION ON WCB CLAIMS

COMMENCING JANUARY 2022 i WILL BE AGAIN AVAILABLE TO PROVIDE ADVOCACY SERVICES

Please complete this form if you are requesting Consultation with Gail Cumming

CONFIDENTIALITY

I am an independent representative and ensure confidentiality to my clients on any WCB issues that are

discussed.

My Initial Consultation for up to one hour is considered at the cost of $125.00

* Indicates required field

ARE YOU AWARE OF THE FEE FOR CONSULTATION? *

Yes No

REQUEST FOR MY REPRESENTATIO AT WCB? *

Yes No Maybe

HAVE YOU CONTACTED ME BEFORE? *

Yes No Unsure

DO YOU CURRENTLY HAVE A REPRESENTATIVE? *

Yes No

NAME *

First

Last

EMAIL *

CONTACT NUMBER *

AGE *

Under 18 19-50 51-64 Over 65 Prefer not to say

DATE OF WCB ACCIDENT *

COMPENSATION RATE INFORMATION *

up to 25,000 $25001 - $50,000 $50001 - $100000 Greater than $100,000

IS YOUR WCB CLAIM ACCEPTED? *

Yes No Unknown

WCB CLAIM NUMBER *

WHAT WCB BENEFITS ARE YOU RECEIVING CURRENTLY? *

Full wage loss Patial wage loss Pension [pre 1995 injury} Other

ARE YOU CURRENTLY WORKING? Choose Any *

No Full duties Modified duties Not full hours

WHAT TYPE OF INJURY OCCURRED? CHOOSE ANY *

Physical Psychological Other

DO YOU HAVE PERMANENT WORKRESTRICTIONS? *

Yes No Unknown

Have you had reviews/appeals completed?Choose Any *

Claim Management level Decision Review and Resolution level Appeals Commission All of the above levels

ADDITIONAL INFORMATION YOU WISH TO PROVIDE *

Submit