Yukon Workers' Compensation Health and Safety Board

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Application for Registration

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

Fields marked in red are required.

A: General Information

Input your Canada Revenue Agency business number.

What is the registered legal name of the company acting as an employer?

Do you carry on business in your legal name?

If you use a name other than your legal name to conduct business, answer 'No'.

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.

Have you had an account with this board before?

Have you received your employer information package?

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.

Payroll Estimate

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

Is the company registered in the Yukon?

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.

Director's name

Estimated 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 earnings.

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.

Purchase optional coverage?

Additional Options

Email a copy of this form to a third party?

Would you like to send a copy of your completed form to someone via email?

Submission Verification

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.