Application for Compensation Benefits - Hearing Loss

  

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

As shown on valid government-issued ID
As shown on valid government-issued ID
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

Employment Information

What is your job title, what do you do?

Work-related injury information

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

Signature, consent and declaration

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