Optional Coverage Cancellation Form

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Optional Coverage Cancellation Form

Optional Coverage Cancellation Form

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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

Legal Name

Trade Name

Primary Phone Number

Customer Number

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

Secondary Phone Number

Coverage Details

Optional coverage cancellation cannot be backdated.

First Name

Last Name

Date optional coverage cancelled

Signature, consent, declaration

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

Date

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