Optional Coverage Cancellation 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.

Please be aware that by cancelling your optional coverage you are no longer protected from lawsuits from other employers and workers for work-related injuries and you are not eligible for compensation benefits in the case of a work-related injury.

Employer Information

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

Coverage Details

Optional coverage cancellation cannot be backdated.
First Name Last Name Date optional coverage cancelled

Signature, consent, declaration