Yukon Workers' Compensation Health and Safety Board

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To ensure we can process the claim quickly, please complete this form as thoroughly as possible.

Fields marked in red are required.

Application for Coverage Outside

If you are sending workers outside Yukon, apply for coverage right away. A decision may take up to 30 days. Workers who leave Yukon before this application is approved with not be covered by YWCHSB. See YWCHSB policy EA-14, "Coverage for Workers Outside Yukon," for more information.

About the employer

Enter the employer’s business name.

Enter the employer's unique YWCHSB account number.

Identify a person we can contact if we need more information about this application.

What number should we use to contact you?

About the work

Clearly identify the location of the work that will be taking place.

Provide details about the type of work the workers identified below will be performing.

About the workers

Select the number of workers that you would like to register for extended coverage.

For work outside Canada

Declaration

I declare:

  • the above information is true and correct to the best of my knowledge;
  • I am authorized to sign this application on the employer's behalf; and,
  • if this form is for workers leaving Canada, I am authorized to permit travel outside of the country on the employer's behalf.

Provide your name as the representative of the employer and individual submitting this application form.

Provide the title of the role you hold with the employer.

Provide your email address so that we may send you a confirmation that this form was successfully submitted.

Today’s date: December 15, 2017

After you submit this form a PDF version will be available for download.

Before submitting this form, please fill out all fields marked in red.

Notes

A worker or a dependent of a deceased worker must claim compensation from YWCHSB within 30 days of an injury that occurs outside Yukon, or it is assumed they will be claiming in the jurisdiction where the injury occurred. Employers are required to report medical and time loss injuries to YWCHSB within 3 days of the injury.

Employers have the right to appeal any assessment-related decision to the Board of Directors within 180 days of the decision, under Section 85 of the Workers' Compensation Act S.Y. 2008.