Application for Compensation Benefits

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

Business Legal Name

What is the name of the business on your paycheque?

Trade Name or Government Department

Street Number

City

Postal Code

Is the physical address the same as mailing address?

Yes No

Employer Contact Name

Provide the name of the person you want us to contact to discuss your claim

Employer Contact Title

Street Name

Province/Territory

Country

Employer Contact Phone Number

Employer Contact Email Address

Worker Information

First Name (As shown on valid government-issued ID)

Middle Name

Last Name (As shown on valid government-issued ID)

Gender

Male Female Other

Date of Birth

Date of worker's death

Social Insurance Number

Needs to be 9 digits long (three sets of 3 numbers)

Employment Information

What was the worker's job at time of the work-related injury?

What is their job title, what did they do?

Was the worker a partner, owner or proprietor in this business?

Yes No

Work-related injury information

Describe, based on the information you have, what happened to cause the incident that lead to the fatality?

Was this a motor vehicle accident?

Yes No

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.

What is your relationship to the deceased worker?

Spouse Dependent Executor of the Estate of the deceased worker Other (please call 667-5645 or toll free 1-800-661-0443 and ask to speak with the manager of Claimant Services)

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 "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.

Do you require an interpreter or translation services?

Yes No

Signature, consent and declaration

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.

By submitting this form, I declare that the information provided is true and correct. I consent to the release from any third party to the Workers' Safety and Compensation Board (board) of any medical, employment or other information relevant to my claim. I consent to the board disclosing to health care 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 understand 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.

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