Application for Compensation Benefits - Standard

Complete the Application for Compensation Benefits form only if you want to apply for loss of earnings and/or medical benefits in the Yukon. You must submit an Application for Compensation Benefits within 12 months of the date of your injury.

To help us process your application as quickly as possible, please complete this form as thoroughly as you can.

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 and return-to-work options

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

For compensation to be payable, you must report your work-related injury to your employer.
Selecting "Yes" does not exclude you from compensation
What time did you start work?
What time did you end work?
Select yes if there was no specific incident that caused this work-related injury

Earnings Information

We will use the information you provide about your earnings to calculate loss of earnings benefit . We will verify the wage information you provide with your employer.

Signature, consent and declaration

This information is being collected for the purpose of administering and enforcing the Workers’ Safety and Compensation Act in compliance with the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the board’s privacy officer at 401 Strickland St., Whitehorse, YT, Y1A 5N8 or call 867-667-5642 or 1-800-661-0443.