Director Exemption Application 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

Legal Name

Last Name

I apply to be deemed not a worker

Corporation Name

I am not working in a Yukon industry and am not exposed to industry hazards. Further, during the year

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

• To the best of my knowledge, I will not receive a T4 or T4A from the corporation.

I will not enter a work site as a worker performing any type of work or services for the corporation.

I will not engage in any directing, negotiating, influencing or decision-making affecting the work of the corporation.

The exception to the two items above is that I may attend the corporation's Annual General Meeting, but I will receive no remuneration for attending. I may also do infrequent bank or legal business.

If the board approves this exemption, I understand: the following:

• I am not considered a worker under Part 4 of the Workers' Safety and Compensation Act and could be sued by another worker or employer.

• I do not have coverage for any injuries arising out of and in the course of employment with the corporation.

• This application covers a maximum of one calendar year. I must re-apply annually for the exemption.

If the board does not approve this exemption, I understand the corporation will be charged assessments on my earnings as a director. If the board later determines that:

• I am issued a T-4 or T4A by the corporation; or

• I went onto a work site as a worker for the purpose of performing work for the corporation, thereby exposing myself to industry hazards; or

• I was directing, negotiating, influencing or decision-making affecting the work of the corporation, thereby working and exposing myself to the hazards of the industry; or

• I filed an application for work performed for the corporation;

The board will terminate this exemption and apply retroactive assessments and administrative fees.

I have read and understand the declarations above. I am aware the board relies on this written application as a true and correct statement.

I understand that, at any time, if the circumstances above change, I am to contact the board.

Signature, consent, declaration

By checking this box I declare that the information provided is true and correct and I acknowledge that electronic communication has inherent security risks, as do all forms of communication. Notwithstanding the inherent risks of electronic communication, I consent to the use of electronic methods to transmit and receive information, including confidential and personal information between the board and myself. This consent will remain in effect until written notice to revoke this authorization has been received by the board.

My name is

My email is

Date