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Forms
Application for registration 2021
Application for registration 2021
Download Printable Form
To ensure we can process the application quickly, please complete this form as thoroughly as possible.
Part A - General information
Canada Revenue Agency BIN #
Input your Canada Revenue Agency business number.
Legal name of employer
What is the registered legal name of the company acting as an employer? This field is required.
Do you carry on business in your legal name?
Yes
No
If you use a name other than your legal name to conduct business, answer 'No'.
Your business address:
Provide the following details about your business address.
Business address street number
Business address street name
Business address box number
Business address city or town
This field is required.
Business address territory or province
This field is required.
Business address Postal code
This field is required.
Business phone numbers
Please provide us with up to 3 phone or fax numbers for your business.
Business phone 1 number
Include area code and use the following format: 123-456-7890. This field is required.
Business phone 1 type
Select one...
Cell
Traditional landline
Fax
Other
Please identify the type of phone that this number is. This field is required.
Business phone 2 number
Include area code and use the following format: 123-456-7890.
Business phone 2 type
Select one...
Cell
Traditional landline
Fax
Other
Business phone 3 number
Include area code and use the following format: 123-456-7890.
Business phone 3 type
Select one..
Cell
Traditional landline
Fax
Other
Email Address
By providing your email address, your permit WSCB to correspond with you by email.
Contact person for payroll
Name the individual or business that manages your payroll. This field is required.
Payroll contact phone
Include area code and use the following format: 123-456-7890. This field is required.
Contact person for claims inquiries
Name the individual at your business who manages claims. This field is required.
Claims contact phone
Include area code and use the following format: 123-456-7890. This field is required.
Previous business owner
Was there a previous owner of the business? If so, identify the business or individual here.
Description of operations
What does your business do? How does it deliver products and services? This field is required.
Location of operations in Yukon
Identify the locations at which you conduct business in the Yukon. This field is required.
If you are working under contract, please provide the name of the contractor
Have you had an account with this board before?
Select one...
Yes
No
Part B - Assessable payroll
When did you first start employing workers in the Yukon?
When did you first hire a worker in the Yukon? This may not be the same as the date you started your business. This field is required.
How many workers including casuals and directors do you have on average?
This field is required.
What is your estimated assessable payroll to December 31st?
This field is required.
To get your estimate:
You must include earning of directors of incorporated companies.
Cannot exceed $91,930 per worker.
Must be for the entire calendar year.
Do not include wages for sole proprietor or partners of non-incorporated companies. Coverage for these is optional.
Part C - Limited companies
Is the company registered in the Yukon?
Select one...
Yes
No
How many directors does the company have?
Please provide a list of names of directors and estimated wages as per part B of this form (above) for each. You can list up to 10 directors using this form.
Part D - Optional coverage
This does not apply to limited companies or Directors of Limited Companies.
If you are self-employed, i.e. as a proprietor or partner, you may apply for compensation coverage for yourself (and/or your partners if you are authorized to do so). Wage loss benefits will be based on the coverage you have purchased to a maximum of 75% of actual proven earnings.
If you are a non-profit society incorporated under the Societies Act, and the Directors perform volunteer work for the society, the Directors may be eligible for coverage. Contact the Board for more information.
Purchase optional coverage?
Select one...
Yes
No
Please contact us at (867) 667-5095 or 1-800-661-0443 to complete your purchase of optional coverage after you've submitted this form.
Part F - Submission verification
Your name
In place of a signature, please verify your identity. This field is required.
Your email address
We’ll send an acknowledgement of this submission to your email address. By providing your email address, your permit WSCB to correspond with you by email. This field is required.
Your phone number
For any follow-up, we'll need your phone number. This field is required.
Please note that your coverage does not begin until your application has been approved by WSCB and you have been contacted by someone at WSCB regarding your coverage. For more information please contact (867) 667-5645 or 1-800-661-0443.
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