Employer's report of injury or illness (F-0036)

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Test Direct Deposit form

Test Direct Deposit form

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This information is being collected for the purposes of administering and enforcing the Workers’ Safety and Compensation Act and is collected under the authority of that Act and the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the Privacy Officer at WSCB at the above listed address or at (867)667-5645 or 1-800-661-0443.

Please be aware that we are unable to deposit to a line of credit, credit card or financial institution outside of Canada.

Please select one of the following
I am an injured worker I am a service provider or vendor

Authorization

I herby authorize WSCB to deposit directly to my account, as noted on the attached encoded cheque/deposit form. This authorization will be in force until notice is given in writing to stop the direct deposit.

Attach a fully encoded blank cheque marked "VOID", or direct form from your bank

Please select a file

Signature, consent, declaration

By checking this box I declare that the information provided is true and correct and I acknowledge that electronic communication has inherent security risks, as do all forms of communication. Notwithstanding the inherent risks of electronic communication, I consent to the use of electronic methods to transmit and receive information, including confidential and personal information between the board and myself. This consent will remain in effect until written notice to revoke this authorization has been received by the board.

My name is

My email is

Date

Terms and Conditions

This authorization is not an assignment of any right to receive payment and revokes all prior payment direction notifications applicable to these payments.
This authorization may be cancelled or changed at anytime with the submission of another form.
Any direct deposit arrangement may be terminated at any time by WSCB or the named financial institution.
The information contained in this application for will only be accessed by the WSCB Finance staff, who require the information to provide payments.