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.

This form is an application for compensation benefits for hearing loss.

If your hearing loss occurred over time, a record of employment history is needed to verify that your Yukon employment history meets the criteria in the policy. Please complete and mail the "Request Template” found at this link: Request to Service Canada for Employment History.

Please note, it can take up to 4 months for Service Canada to return your employment history. In order to avoid any further delays in your claim, please submit your employment history to the board, as soon as you receive it.

Worker Information

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

Middle Name

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

Also Known As

Primary Phone Number

Secondary Phone Number

Work Phone Number

Street Number

Street Name

City

Province/Territory

Country

Postal Code

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

Is the physical address the same as mailing address?

Yes No

Gender

Male Female Other

Date of Birth

Do you require an interpreter or translation services?

Yes No

Employment Information

What was your job at time of the work-related injury?

What is your job title, what do you do?

Are you a partner, owner or proprietor in this business?

Yes No

Work-related injury information

Have your reported this work related injury to your employer?

Yes No

Describe in detail what equipment or environment you believe is the cause of your hearing loss?

Did your work-related injury occur on your employer's premises?

Yes No

Do you have a claim for hearing loss or ear injury with any other workers’ compensation board in Canada?

Yes No

Did your work-related injury happen in the Yukon?

Yes No

Have you been exposed to gunfire?

Yes No

Date you were first diagnosed with hearing loss?

Other than hearing loss, have you ever seen a doctor about your ears?

Yes No

Where did you get your hearing test?

If you received medical attention outside of the Yukon, please provide the name, city and province of that medical office

Have you missed work due to your hearing loss?

Yes No

Signature, consent and declaration

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.

Please ensure that your Service Canada employment report and a copy of your hearing report are submitted once you have them.

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