2022 Optional Coverage Form - Volunteers, Elected or Appointed First Nation Officials

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If this application is approved by the board, the following terms and conditions apply:
  • the applicant must be a registered employer under the Workers' Safety and Compensation Act
  • volunteers: the amount of coverage that must be purchased for each individual is equal to half the maximum annual earnings for the current year (coverage amount cannot exceed this amount)
  • elected or appointed officials: the amount of coverage must closely reflect the actual employment earnings of the individual and is subject to the maximum annual earnings amount for the current year
  • coverage may be purchased for a period of time less than one year but not for 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 EL-01 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
  • it is the employer’s responsibility to inform the individuals of coverage that has been approved under this application
  • if this application is approved the individuals will be deemed to be the workers of the applicant and the applicant will be deemed to be the employer of the individuals under the Workers' Safety and Compensation Act

Employer Information

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

Coverage Details

Signature, consent, declaration