CHOICES Enrollment

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CHOICES Enrollment

CHOICES Enrollment

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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 note that WSCB may verify or audit any of the information you have provided on this form.

Employer Information

Legal Name

If incorporated, use the legal name as listed on your Articles of Incorporation. If not incorporated, the legal name should be the name of the owner(s).

Trade Name

The trade name is the name most recognized by the public and customers.

Customer Number

This number can be found in the email we sent you to complete your annual report or on any of your invoices or statements. Example: 12345-54321

Email Address

Has the business been sold?

Yes No

CHOICES Incentive Rebate Program

CHOICES is a voluntary employer incentive program that recognizes and rewards employers with rebates for workplace training investments made in workplace health and safety and/or return to work.

For more information please see Policy 7.1 CHOICES Incentive Program

Is your business COR/SECOR or COR equivalency certified (Certificate of Recognition Safety Program)?

Yes No

Signature, Consent and Declaration

Please read and review carefully

By my submission I certify and declare the following: I have the authority to execute this report on behalf of the business; and the facts set forth are true and correct to the best of my knowledge and belief. I fully understand the content, the requirements of the submission, and that WSCB will use and rely on this information in the management of our business account. I am aware that any person who knowingly provides false information or misleading information or omits to provide any relevant information to the board may be subject to administrative penalties or may be guilty of an offence under the WSCA. The information I reported will be used to determine my premium.

By checking this box, I confirm this is my digital signature.

Signature

Today's Date

My position is

My email is

If you are submitting a PDF form, please submit your completed form using the following link: wcb.yk.ca/filedrop