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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.

Complete the Application for Compensation Benefits form only if you want to apply for loss of earnings and/or medical benefits in the Yukon. You must submit an Application for Compensation Benefits within 12 months of the date of your injury.

To help us process your application as quickly as possible, please complete this form as thoroughly as you can.

Please allow 30 to 40 minutes to complete this form

Worker Information

First Name (As shown on valid government-issued ID)

Middle Name

Last Name (As shown on valid government-issued ID)

Also Known As

Primary Phone Number

Secondary Phone Number

Work Phone Number

Street Number

Apartment Number/Unit Number

Street Name

City

Province/Territory

Country

Postal Code

Is the physical address the same as mailing address?

Yes No

Gender

Male Female Other

Do you require an interpreter or translation services?

Yes No

Date of Birth

Employer Information

Business Legal Name

What is the name of the business on your paycheque?

Trade Name or Government Department

Street Number

City

Postal Code

Street Name

Province/Territory

Country

Employer Contact Name

Provide the name of the person you want us to contact to discuss your claim and return-to-work options

Employer Contact Title

Employer Contact Phone Number

Employer Contact Email Address

Is the physical address the same as mailing address?

Yes No

Work-Related Injury Information

For compensation to be payable, you must report your work-related injury to your employer.

Date of work-related injury

Time of work-related injury

What was your job at time of the work-related injury?

What is your job title, what do you do?

Are you a partner, owner or proprietor in this business?

Yes No

Have your reported this work related injury to your employer?

Yes No

What happened to cause your work-related injury?

What part of your body was injured?

Has this part of your body been injured before?

Yes No

Selecting "Yes" does not exclude you from compensation

What equipment were you using?

Were you doing work for your employer when you got injured?

Yes No

Did your work-related injury occur on your employer's premises?

Yes No

What were your hours of work on the day you were injured?

What time did you start work?

What time did you end work?

Did your work-related injury happen in the Yukon?

Yes No

Did you receive medical attention?

Yes No

Was this a motor vehicle accident?

Yes No

Did accident involve a train, plane or automobile?

Is your injury a psychological injury?

Yes No

Earnings Information

We will use the information you provide about your earnings to calculate loss of earnings benefit . We will verify the wage information you provide with your employer.

How long have you worked in this job?

Did you miss time from work after the day of your work-related injury?

Yes No

Please describe your current employment status

Seasonal Full-time Part-time Piecework Retired

Is your employer continuing to pay you?

Yes No Unknown

Do you have another job or other sources of employment income?

Yes No

Have you returned to work?

Yes - regular duties Yes - modified duties No

When did you return to work?

Signature, consent and declaration

Email communication

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.

Declaration

By submitting this form, I declare that the information provided is true and correct. I consent to the release from any third party to the Workers' Safety and Compensation Board (board) of any medical, employment or other information relevant to my claim. I consent to the board disclosing to health care providers, hospitals, physicians, my employers, other workers' compensation boards and any other relevant third parties, all relevant information necessary to administer my claim in accordance with the law. I understand that my social insurance number may be used for reporting to Canada Revenue Agency and collecting information from Canada Revenue Agency for the purpose of determining benefit entitlement.

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