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Application for extended coverage outside Canada
Application for extended coverage outside Canada
Download Printable Form
If you are sending workers outside Canada, apply for coverage right away. A decision may take up to 30 days. Workers who leave Yukon before this application is approved are not covered. See YWCHSB Policy EA-14, “Coverage for Workers Outside Yukon”, for more information. To ensure we can process the claim quickly, please complete this form as thoroughly as possible.
Employer information
Customer #
Enter the employer's unique YWCHSB account number.
Business name
Enter the employer's business name. This field is required.
Authorized contact
Identify a person we can contact if we need more information about this application.
Phone number
What number should we use to contact you? This field is required.
Fax number
Email
By providing your email address, you permit YWCHSB to correspond with you by email. To withdraw your email from our system, contact us.
About the work planned
Exact location (province/territory/state, country)
Clearly identify the location of the work that will be taking place (province/territory/state, country). This field is required.
Description of work planned.
Provide details about the type of work the workers identified below will be performing. This field is required.
About the workers
How many workers are you applying to cover?
Select the number of workers that you would like to register for extended coverage. You must register at least one worker and can register up to 5 using this form. This field is required.
About worker 1
Full legal name of worker 1
This field is required.
Years/months employed by this employer in Yukon
This field is required.
Departure date
This field is required.
Return date
This field is required.
I have verified this worker is a Yukon resident
Select one...
Yes
No
This field is required.
Continuation of work outside Canada
Is the work a continuation of the work performed in the Yukon?
If your workers will be traveling outside of Canada, you must answer the following questions.
About your workers’ health and safety while working abroad
Declaration
I declare that the above information is true and correct to the best of my knowledge and that I am authorized to submit this application on the employer’s behalf. I acknowledge that I have read and understand my responsibilities. I am authorized to permit travel outside of Canada on the employer’s behalf.
Your name
Provide your name as the representative of the employer and individual submitting this application form. This field is required.
Your title
Provide the title of the role you hold with the employer. This field is required.
Your email
Provide your email address so that we may send you a confirmation that this form was successfully submitted. This field is required.
Notes
Note: A worker or dependent of a deceased worker must file a claim for compensation from YWCHSB within 30 days of an injury that occurs outside Yukon. Employers are required to report medical and time loss injuries to YWCHSB within 3 days of receiving notice of an injury.
Employers have the right to appeal any assessment-related decision to the Board of Directors within 180 days of the decision under Section 85 of the Workers’ Compensation Act S.Y. 2008. This information is being collected for the purposes of administering and enforcing the Workers’ 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 YWCHSB at the above listed address or at 867-667-5645 or 1800-661-0443.
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