Application for Coverage Outside Canada Form

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.

If you have workers (Yukon resident or usual place of work is in Yukon) performing work outside Yukon and that work is a continuation of the work they normally perform in Yukon, the workers are covered under the Act for work-related injuries. A worker is considered a resident of Yukon if their usual place of permanent residency is in Yukon. This coverage outside Canada is limited to a consecutive period of less than 14 consecutive days for work outside Canada.

No application is required if the work falls within this time period.

Employer information

Legal Name

Trade Name

Customer Number

12345-12345 (5 digits all numbers - 5 digits all numbers)

CRA BIN Number

Street Number

Street Name

City

Province/Territory

Postal Code

Country

Email

Primary Phone Number

Secondary Phone Number

About the work planned

What exact location (state/country) will your workers be working in?

i.e. San Jose, Costa Rica

Is the work they are performing for you outside Yukon required to be performed both in Yukon and outside Yukon in the normal course of their employment?

Yes No

I have verified that my workers will have access to health care services similar to Yukon

Yes No

I have verified there are no concerns with civil unrest or other security concerns that affect the personal safety of my workers

Yes No

How many workers will be working outside Canada?

Select the number of workers that you would like to register for extended coverage. You must register at least one worker and can register up to 5 using this form.

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 checking this box I declare that the information provided is true and correct. I consent to the release from any third party to 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.

My name is

My email is

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