Application for Compensation Benefits - Worker Fatality

  

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.
You only need to complete the Application for Compensation Form if you want to apply for compensation benefits in the Yukon. An application for compensation must be submitted with in 12 months of the date of injury or death.

Please allow 30 to 40 minutes to complete this form.

Employer Information

What is the name of the business on your paycheque?
Provide the name of the person you want us to contact to discuss your claim

Worker Information

As shown on valid government-issued ID
As shown on valid government-issued ID
Needs to be 9 digits long (three sets of 3 numbers)

Employment Information

What is their job title, what did they do?

Work-related injury information

Did accident involve a train, plane or automobile?

Applicant Information

The information you provide in this section will helps us determine eligibility for compensation for a spouse, dependent(s) or the estate of a deceased worker.
a "spouse" in respect of a worker means the individual who, at the date of the worker’s death, lived with the worker, and
    (a) to whom the worker was legally married at the date of the worker’s death, or
    (b) with whom the worker had lived as a couple for at least 12 months immediately before the worker’s death

a "dependent" means a member of the family of a worker who is wholly or partially dependent on the worker’s earnings for the ordinary necessities of life or who, but for the worker’s work-related injury, would have been so dependent

a "Executor/Administrator" is a person appointed by a will or by the courts to manage an estate. The executor is the personal representative of the estate and is trusted by the creditors and beneficiaries of the estate.

Signature, consent and declaration