This form has a deadline
This report must be submitted to the Yukon Workers' Compensation Health and Safety
Board ASAP. Employers will be fined if this report is not received within 3 days
of when you become aware of the injury. It can be faxed, mailed, or dropped off
at our office.
Major injury notice
Major injuries (including fractures, loss of consciousness, etc.) must be reported
to the Yukon Workers' Compensation Health and Safety Board IMMEDIATELY. Call (867) 667-5450 or 1-800-661-0443.
What is the worker's home address?
Home Telephone Number:
What is the worker's home telephone number?
Work Telephone Number:
Does the worker have a direct telephone line at work?
Where do you send email to reach the worker?
What is the worker's job?
Who supervised the worker?
Employer's telephone number:
What is your company's main telephone number?
Employer's cell number:
Is there a cell number we can reach you at?
What is the name of your employer?
If you work for the Yukon Government, in what department?
What is the full mailing address of your employer?
Tell Us About the Worker's Injury/Illness
Date of injury/illness:
If the injury occurred over time, indicate the date that the worker first reported problems to you.
Indicate the time at which the injury occurred.
If the worker was physically injured, identify what part of the body was injured.
Describe how the worker was injured.
Where did the worker get hurt?
Time Loss Claim
If Yes, when?
Who handles payroll in your organization?
In place of a signature, please verify your identity.
We’ll send an acknowledgement of this submission to your email address.
Your phone number:
For any follow-up, we’ll need your phone number.
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.