Worker's report of injury/illness

To ensure we can process the claim quickly, please complete this form as thoroughly as possible.

Tell us about you

This field is required.
This field is required.
This field is required.
What is your home address? This field is required.
What is your home telephone number?
Do you have a direct telephone line at work?
Do you have a cell phone?
What is your primary email address? We’ll use this address to contact you.
What is your job?
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.
What is your supervisor’s name?
What is your supervisor’s phone number? This field is required.
What is your supervisor's cell phone number?

Tell us about your injury/illness

Describe how you were injured. This field is required.
If you were physically injured, identify what part of your body was injured. This field is required.
If you had a similar injury before identify it here.
Provide the name of the person you initially reported your injury/illness to
Provide the time you began work and the time you ended work
This field is required.

Signature, consent and declaration

I declare that the information provided is true and correct. I consent to the release from any source to Yukon Workers' Compensation Health and Safety Board (YWCHSB) of any medical or employment information relevant to my claim. I consent to YWCHSB disclosing to healthcare 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 acknowledge that YWCHSB may collect information it considers relevant to my claim to determine benefit entitlement and 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 in accordance with the law.
This field is required.
This field is required.
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This information is collected, used and disclosed under the authority of the Workers' Compensation Act and the Access to Information and Protection of Privacy Act for the purposes of administering and enforcing the Workers' Compensation Act. For further information, please contact 867-667-5645 or 1-800-661-0443.
This tool helps us reduce unauthorized submissions being made through this form.