A: General Information
Input your Canada Revenue Agency business number.
What is the registered legal name of the company acting as an employer?
Provide the name under which you conduct business.
Name the individual or business that manages your payroll.
Name the individual at your business who manages claims.
Was there a previous owner of the business? If so, identify the business or individual here.
What does your business do? How does it deliver products and services?
Identify the locations at which you conduct business in the Yukon.
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.
To get your estimate:
- You must include earning of Directors of Incorporated companies.
- Cannot exceed $85,601 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. Call the YWCHSB if you are interested in coverage.
C: Limited Companies
Please provide a list of names of Directors and estimated wages as per section B for each.
Provide the legal name of the Director, identify the total estimated value of the work he or she contributes to the business, and the actual amount he or she receives in wages.
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
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.
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.
In place of a signature, please verify your identity.
We’ll send an acknowledgement of this submission to your email address.
For any follow-up, we'll need your phone number.
Please note that your coverage does not begin until your application has been approved
by YWCHSB and you have been contacted by someone at YWCHSB regarding your coverage.
For more information please contact (867) 667-5645 or 1-800-661-0443.
Before submitting this form, please fill out all fields marked in red.
*By providing your email address, your permit YWCHSB to correspond with you by email.
After you submit this form a PDF version will be available for download.