Employer's report of injury/illness

To ensure we can process the application quickly, please complete this form as thoroughly as possible.
This report must be submitted to Yukon Workers' Compensation Health and Safety Board ASAP. Employers will be fined if this report is not received within 3 days of when you become aware of the injury. It can be faxed, mailed, or dropped off at our office.
Major injuries (including fractures, loss of consciousness, etc.) must be reported to the Yukon Workers' Compensation Health and Safety Board IMMEDIATELY. Call 867-667-5450 or 1-800-661-0443.

Tell us about your worker

This field is required.
This field is required.
What is the worker's home address? This field is required.
What is the worker's home 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? This field is required.
Who supervised the worker?
What is your company's main telephone number? This field is required.
Is there a cell number we can reach you at?
What is the name of your employer? This field is required.
If you work for the Government of Yukon, in what department?
What is the full mailing address of your employer? This field is required.

Tell us about the worker's injury/illness

If the injury occurred over time, indicate the date that the worker first reported problems to you. This field is required.
Indicate the time at which the injury occurred.
Please indicate left or right side. This field is required.
Describe how the worker was injured. This field is required.
This field is required.
Where did the worker get hurt?
This field is required.
This field is required.

Submission verification

In place of a signature, please verify your identity. This field is required.
We’ll send an acknowledgement of this submission to your email address. This field is required.
For any follow-up, we’ll need your phone number. This field is required.
This tool helps us reduce unauthorized submissions being made through this form.