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

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

About the work planned

i.e. San Jose, Costa Rica
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