Enter the employer's unique YWCHSB account number.
Enter the employer's business name. This field is required.
Identify a person we can contact if we need more information about this application.
What number should we use to contact you? This field is required.
By providing your email address, you permit YWCHSB to correspond with you by email. To withdraw your email from our system, contact us.
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.
Provide your name as the representative of the employer and individual submitting this application form. This field is required.
Provide the title of the role you hold with the employer. This field is required.
Provide your email address so that we may send you a confirmation that this form was successfully submitted. This field is required.
Note: A worker or dependent of a deceased worker must claim compensation from YWCHSB within 30 days of an injury that occurs outside Yukon, or it is assumed they will be claiming in the jurisdiction where the injury occurred. Employers are required to report medical and time loss injuries to YWCHSB within 3 days of the 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.
This tool helps us reduce unauthorized submissions being made through this form.