Other Registration

You will need the following information to complete this form:

a) legal name of your business
b) CRA business number if you have one;
c) description of business activities and primary business purpose;
d) full names of owners, birth dates and addresses of proprietor or partners
e) payroll information, estimate of annual payroll;
f) information about contractors or subcontractors.

Employer Information

Legal Name

Trade Name

CRA BIN Number

Street Number

Street Name

City

Province/Territory

Postal Code

Country

Is the physical address the same as mailing address?

Yes No

Email

Primary Phone Number

Secondary Phone Number

Fax Number

Have you had an account with Workers' Safety and Compensation Board in the Yukon before?

Yes No

What date will your workers start to work in Yukon?

Business Contact Information

Payroll Contact First Name

Payroll Contact Last Name

Payroll Contact Phone Number

Payroll Contact Email

Claims Contact First Name

Claims Contact Last Name

Claims Contact Phone Number

Claims Contact Email

WHS Contact First Name

WHS Contact Last Name

WHS Contact Phone Number

WHS Contact Email

Employer Business Information

Is the Yukon your home jurisdiction?

Yes No

Your home jurisdiction is where your head office is.

How many workers including casuals do you have on average? Do not include owner/operator or partners.

1-10 11-25 26-50 51 or more

Please describe your business activities and primary business purpose.

What types of products, goods or services does your business provide?

What type of tools are used?

Do you have more than one business purpose?

Yes No

Please provide the location of your workplace in the Yukon.

“Workplace” means a building, site, project site, workshop, structure, vehicle or mobile equipment, or any other location where one or more workers perform or have performed work.

Has your business been contracted by any other business to do work in the Yukon?

Yes No

Payroll Information

For your workers, excluding the proprietor (owner/operator) or partners, that are working in the Yukon, what is your estimated assessable payroll to December 31?

Your total estimate is the amount of payroll for each worker for the time they are working in the Yukon (do not exceed the maximum annual earnings per worker). Requested coverage amount, not to exceed the maximum annual earnings of $98093 for 2023. Only enter the numeric value, no added symbols, i.e. 91500

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, YK, Y1A 5N8 or call 867-667-5642 or 1-800-661-0443.

By checking this box, 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.

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

My name is

My email is

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