Yukon Workers' Compensation Health and Safety Board

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To ensure we can process the application quickly, please complete this form as thoroughly as possible.

Fields marked in red are required.

Employer's Report of Injury/Illness

This form has a deadline

Major injury notice

Worker's Name:

Gender:

What is the worker's home address?

Home Telephone Number:

What is the worker's home telephone number?

Work Telephone Number:

Does the worker have a direct telephone line at work?

Where do you send email to reach the worker?

What is the worker's job?

Who supervised the worker?

Employer's telephone number:

What is your company's main telephone number?

Employer's cell number:

Is there a cell number we can reach you at?

During your busy periods, do you regularly employ 20 or more workers?

What is the name of your employer?

If you work for the Yukon Government, in what department?

What is the full mailing address of your employer?

Tell Us About the Worker's Injury/Illness

Date of injury/illness:

If the injury occurred over time, indicate the date that the worker first reported problems to you.

Time:

Indicate the time at which the injury occurred.

If the worker was physically injured, identify what part of the body was injured.

Describe how the worker was injured.

Do you have any reason to believe this claim should be denied?

Has the worker sent in a Worker’s Report of Injury/Illness?

Where did the worker get hurt?

Was first aid given at the work site?

Did the injury/illness happen on the employer’s premises?

Was the worker doing work for the employer when the injury occurred?

Did the worker seek medical attention beyond the work site?

Did the worker miss work after the date of injury/illness?

If yes, this is a Time Loss Claim. Please complete the following section.

Time Loss Claim

Has the worker returned to work?

If Yes, when?

If no, have your created a Return-to-Work Plan?

Who handles payroll in your organization?

Telephone:

Submission Verification

In place of a signature, please verify your identity.

We’ll send an acknowledgement of this submission to your email address.

Your phone number:

For any follow-up, we’ll need your phone number.

After you submit this form a PDF version will be available for download.

Before submitting this form, please fill out all fields marked in red.