CONSENT FOR DISCLOSURE OF PERSONAL INFORMATION TO A REPRESENTATIVE

Why fill out this form?

You do not need to complete this form if you have already designated a representative when submitting your Notice of Appeal.

You do not need a representative to file an appeal. However, if you choose to have one, your personal information cannot be released to your representative without your written consent.

By providing written consent, the Employment Insurance (EI) Board of Appeal will communicate with your authorized representative regarding the appeal. Only the information received by the EI Board of Appeal in relation to the appeal can be disclosed. This can include:

• the reconsideration file containing all the information used by the Canada Employment Insurance Commission to make their decision under section 112 of the Employment Insurance Act
• the representations of the Commission explaining the reasoning for its decision
• any information/communication about the appeal
• the decision of the EI Board of Appeal

In addition, you authorize your representative to communicate with and receive information from the EI Board of Appeal regarding any matter related to the appeal process. This allows the person to attend the hearing and speak on your behalf. You are responsible for any costs incurred.

Privacy statement

Your personal information on this form is collected under the authority of the Department of Employment and Social Development Act and the BOA Regulations to process an appeal of an Employment Insurance reconsideration decision to the Board of Appeal. Completion of this form is voluntary however refusal to provide the requested personal information may result in the form being considered incomplete or ineligible for processing. Your personal information is protected under the Privacy Act and accessible under the Access to Information Act. It will only be used and disclosed as described in the Personal Information Bank titled the “Employment Insurance Claim Files” (ESDC/PPU 151). Instructions for obtaining this information are outlined in the government publication entitled Info Source available at www.canada.ca/infosource-ESDC. You also have the right to request access to your personal information and to request corrections, should you believe the information you provided contains errors or omissions. To request a correction to your personal information, please contact ESDC ATIP office at: NC-COMM-ATIP-AIPRP-GD@hrsdc-rhdcc.gc.ca. If you are not satisfied with our response to your privacy concern or the handling of your personal information, you may contact the Office of the Privacy Commissioner of Canada at www.priv.gc.ca/en/report-a-concern.