Worker's Name:
What is your home address?
Home Telephone Number:
What is your home telephone number?
Work Telephone Number:
Do you have a direct telephone line at work?
What is your primary email address? We’ll use this address to contact you.
What is your job?
What is your supervisor’s name?
Supervisor's telephone number:
What is your supervisor’s phone number?
Supervisor's cell number:
What is your supervisor’s cell phone number?
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 Your Injury/Illness
Describe how you were injured.
When is getting hurt at work not covered by workers' compensation?
Workers' compensation provides coverage for most injuries that happen while doing work assigned by your employer, but there are exceptions.
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(Don't worry – you won't lose this
form)
Yukon Workers' Compensation Health and Safety Board
Staff (“adjudicators”) look at each claim to see if it qualifies, under the law,
as an injury covered by workers’ compensation.
To qualify, each of the following must be true:
- You have to be a worker under our Act. In very general terms, this means you were
working for an employer when the injury happened;
- You have to be working in an industry covered under our Act. There is a list of
industries not covered by us, which includes employees of the Federal government
and other federally regulated industries;
- You have to have an injury or illness;
- The injury or illness has to have been caused by your work duties, during work hours;
- The injury or illness must not have been deliberately self-inflicted.
If you were physically injured, identify what part of your body was injured.
Date of injury/illness:
If your injury/illness occurred over time, when did you first experience symptoms?
Provide the name of the person you initially reported your injury/illness to
When did you report the injury/illness?
What were your hours of work on the day of the injury/illness?
From:
When?
Returning to work in some capacity as soon as it is safe to do so is an important part of the recovery process.
Our Return-To-Work consultant will contact you / your employer shortly to see how we can assist in planning your safe and early return to work.
If Yes, when?
Additional Options
Signature, Consent and Declaration
I declare that the information provided is true and correct. I consent to the release
from any source to the Yukon Workers' Compensation Health and Safety Board (YWCHSB)
of any medical or employment information relevant to my claim. I consent to YWCHSB
disclosing to healthcare providers, hospitals, physicians, my employers, other workers'
compensation boards, and any other relevant third parties, all relevant information
necessary to administer my claim in accordance with the law.
I acknowledge that the YWCHSB may collect information it considers relevant to my
claim to determine benefit entitlement and that my social insurance number may be
used for reporting to Canada Revenue Agency and collecting information from Canada
Revenue Agency for the purpose of determining benefit entitlement in accordance
with the law.
Today’s date: July 28, 2017
This information is collected, used and disclosed under the authority of the Workers'
Compensation Act and the Access to Information and Protection of Privacy Act for
the purposes of administering and enforcing the Workers' Compensation Act. For further
information, please contact (867) 667-5645 or 1-800-661-0443.
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.