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Employer's report of injury or illness
Employer's report of injury/illness
Download Printable Form
To ensure we can process the application quickly, please complete this form as thoroughly as possible.
This report must be submitted to Workers' Safety and Compensation 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 Workers' Safety and Compensation Board IMMEDIATELY. Call 867-667-5450 or 1-800-661-0443.
Tell us about your worker
Worker's last name
This field is required.
Worker's first name
This field is required.
Middle initial
Worker's gender
Select one...
Male
Female
Other
Worker's mailing address
What is the worker's home address? This field is required.
Home phone number
What is the worker's home telephone number?
Work phone number
Does the worker have a direct telephone line at work?
Email address
Where do you send email to reach the worker?
Worker's occupation
What is the worker's job? This field is required.
Name of supervisor
Who supervised the worker?
Employer's phone number
What is your company's main telephone number? This field is required.
Employer's cell number
Is there a cell number we can reach you at?
During your busy periods, do you regularly employ 20 or more workers?
Yes
No
Employer's name
What is the name of your employer? This field is required.
Department (for Government of Yukon only)
If you work for the Government of Yukon, in what department?
Employer's mailing address
What is the full mailing address of your employer? This field is required.
Are you a partner, owner or proprietor in this business?
Yes
No
Please select
Partner
Owner
Proprietor
Tell us about the worker's injury/illness
Date of injury/illness
If the injury occurred over time, indicate the date that the worker first reported problems to you. This field is required.
Time
Indicate the time at which the injury occurred.
What equipment was being used?
What part of the body was injured?
Please indicate left or right side. This field is required.
What happened?
Describe how the worker was injured. This field is required.
Do you have any reason to believe this claim should be denied?
Select one...
No
Yes
This field is required.
When was the injury/illness reported to the supervisor?
Has the worker sent in an Application for Compensation Benefits form?
No
Yes
City, town or place of injury/illness
Where did the worker get hurt?
Was first aid given at the work site?
No
Yes
Did the injury/illness happen on the employer’s premises?
No
Yes
Was the worker doing work for the employer when the injury occurred?
Select one...
Yes
No
This field is required.
Did the worker seek medical attention beyond the work site?
No
Yes
Did the worker miss work after the date of injury/illness?
Select one...
No
Yes
This field is required.
Submission verification
Your name
In place of a signature, please verify your identity. This field is required.
Your email address
We’ll send an acknowledgement of this submission to your email address. This field is required.
Your phone number
For any follow-up, we’ll need your phone number. This field is required.
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