Request for Disclosure of Employer Assessment Decision/Administrative Penalty

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Request for Disclosure of Employer Assessment Decision/Administrative Penalty

Request for Disclosure of Employer Assessment Decision/Administrative Penalty

Download Printable Form

Complete and submit this form to receive information relating to an employer assessment decision. For more information about requests for disclosure please contact the Information Management Unit at 867-667-5645.

This information is being collected for the purposes of administering and enforcing the Workers’ Safety and Compensation Act and is collected under the authority of that Act and the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the Privacy Officer at WSCB at the above listed address or at (867)667-5645 or 1-800-661-0443.

I am the

Employer Employer's representative

If you are a worker’s representative or employer’s representative, an Authorization for Representation form from the worker or employer must accompany this request, if not previously submitted. Click here for the Authorization of a Representative form.

Authorization form previously submitted

Applicant Information

First name

As shown on government ID

Last name

Street number

Street name

City

Province/Territory

Postal code

Country

Employer Assessment Decision

Relevant information relating to

Employer assessment decision Administrative penalty

Employer name

Employer customer number

Additional details

Receiving Disclosure

Please choose one of the following

mail to my contact address on this form secure email to my contact email on this form pickup at 401 Strickland Street Whitehorse, YT Y1A 5N8

Signature, Consent & Declaration

By checking this box, I acknowledge that electronic communication has inherent security risks, as do all forms of communication. Notwithstanding the inherent risks of electronic communication, I consent to the use of electronic methods to transmit and receive information, including confidential and personal information between the board and myself. This consent will remain in effect until written notice to revoke this authorization has been received by the board.

My name

My email

If you are submitting a PDF form, please submit your completed form using the following link: wcb.yk.ca/filedrop