Optional Coverage Form - Proprietors/Partners

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Optional Coverage Application
Optional Coverage Form - Proprietors/Partners

Optional Coverage Form - Proprietors/Partners

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If this application is approved by the board, the following terms and conditions apply:

the amount of coverage purchased must closely reflect your actual employment earnings and is subject to the maximum annual earnings amount for the current year.
in the event of an injury the board may require documentation verifying earnings.
coverage may be purchased for a period of time less than one year but not for a period less than one month (coverage cannot extend past December 31)
coverage is not effective until the application has been approved by the board.
coverage expires December 31 unless an earlier date is requested and must be renewed annually.
the minimum assessment premium is $150.00.
in the event of a work-related injury, an individual covered by optional coverage can submit a claim and may be eligible for compensation benefits. If the claim is accepted, loss of earnings benefits will be calculated in accordance with policy 3.1 Loss of Earnings Benefits.
the board may cancel coverage if the account is not in good standing, false or misleading information has been provided to the board or required information has not been provided to the board
if this application is approved you must complete the application for registration
if this application is not granted you will be advised in writing the reasons for denial
if this application is approved the individual will be deemed to be the worker of the applicant and the applicant will be deemed to be the employer of the individual under the Workers' Safety and Compensation Act

Employer Contact Information

Legal Name

Trade Name

Customer Number

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

Street Number

Street Name

City

Province/Territory

Postal Code

Primary Phone

Secondary Phone

Email Address

Worker Contact Information

First Name

Middle Name

Last Name

Street Number

Street Name

PO Box

City

Province/Territory

Country

Postal Code

Primary Phone

Secondary Phone

Email Address

Coverage Details

Coverage Amount

Requested coverage amount, not to exceed the maximum annual earnings of $98093 for 2023 $102017 for 2024. Only enter the numeric value, no added symbols, i.e. 91500

Coverage Start Date

Please choose a date that is either today’s date or a date in the future. Coverage is not effective until this application has been approved by the board and will not be backdated.

Coverage End Date

This date must be 30 days or more and cannot extend past December 31 of the current year.

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 867-667-5645 or 1-800-661-0443.

By checking this box I declare that the information provided is true and correct. 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.

My name is

My email is

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