Application for Compensation Benefits - Standard

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.
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.

Worker Information

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

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

Work-Related Injury Information

For compensation to be payable, you must report your work-related injury to your employer.
What is your job title, what do you do?
Selecting "Yes" does not exclude you from compensation
What time did you start work?
What time did you end work?
Did accident involve a train, plane or automobile?
Do any of the following apply to you?

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