Wage Loss - Verification of Information

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, YT, Y1A 5N8 or call 867-667-5645 or 1-800-661-0443.
If you are entitled and receiving wage loss benefits, you need to have your wage loss compensation reviewed every year. Please fill out and submit the Wage Loss Verification of Information form to the board. Make sure your health care provider fills out and submits the wage loss annual medical report, which you can find on the website or by using the link provided after you submit the Wage Loss Verification of Information form.

You need to submit your wage loss forms by July 2nd. If you can't do this, contact your case manager before that date.

Worker Information

As shown on valid government-issued ID

Self-Report of Functional Abilities

Income Information


Signature, consent and declaration