Director Exemption Application Form

Home
Forms
Director Exemption Application Form

Director Exemption Application Form

Download Printable Form

This information is being collected for the purposes of administering and enforcing the Workers’ Safety and 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 WSCB at the above listed address or at (867)667-5645 or 1-800-661-0443.

Director Information

Exemption application year

First Name

Last Name

I apply to be deemed not a worker under Part 4 of the Workers' Safety and Compensation Act

Corporation Name

I am a "non working director" and am not active in the corporation's operations in the Yukon and and not subject to the hazards of the industry of the corporation

I will not receive any employment earnings from the corporation, including salary, wages, tips, commissions, bonuses, allowances or directors’ fees. (Dividends are not considered employment earnings)

I am not performing any work for the corporation while acting in my capacity as a director in the Yukon (no directing, negotiating, influencing or decision-making affecting work, and no visits to the corporation's worksites to perform services)

I do not receive a T4 or T4A from the corporation (Except for fees related to attending annual general meetings and other incidental duties as a director)

If the board approves this exemption, I understand:

• I am not entitled to compensation benefits in the case of a work-related injury

• The corporation and non-working director do not have immunity from civil lawsuits arising from work-related injuries

• I must file an exemption application to the board each year

If at any time my circumstances change, the corporation and I are both responsible to notify the board as soon as possible. Failure to provide timely notice may result in additional assessments, fees and penalties.

If the board does not approve this exemption the corporation will be responsible for reporting my employment earnings to the board and paying assessments on my employment earnings as a director.

Signature, consent, declaration

By checking this box, I am attesting that I understand the above and declare that the information provided is true and correct. I consent to the use of electronic methods to transmit and receive information, including confidential and personal information between the board and myself.

Name

Date