Wage Loss - Verification of Information

This information is being collected for the purpose of administering and enforcing the Workers’ Safety and Compensation Act in compliance with the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the board’s privacy officer at 401 Strickland St., Whitehorse, YT, Y1A 5N8 or call 867-667-5645 or 1-800-661-0443.

If you are entitled and receiving wage loss benefits, you need to have your wage loss compensation reviewed every year. Please fill out and submit the Wage Loss Verification of Information form to the board. Make sure your health care provider fills out and submits the wage loss annual medical report, which you can find on the website or by using the link provided after you submit the Wage Loss Verification of Information form.

You need to submit your wage loss forms by July 2nd. If you can't do this, contact your case manager before that date.

Worker Information

Claim Number

First Name

Middle Name

Last Name

As shown on valid government-issued ID

Street Number

Apartment Number/Unit Number

Street Name

City

Province/Territory

Country

Postal Code

Primary Phone Number

Is the physical address the same as mailing address?

Yes No

Self-Report of Functional Abilities

Please select your injury type

Physical Psychological

In the last 12 months, have your workplace injury symptoms

increased decreased stay the same

Please explain

What are you doing to manage your workplace injury?

exercise following up with your health care provider medication other none

If you have a claim accepted for a physical injury, has there been a change in the last year in your ability to participate in activities involving

walking sitting, climbing stairs/ladder lifting bending, twisting and kneeling other

Please explain the changes

If you have a claim accepted for a psychological injury, has there been any changes in the last year, in the following

concentration participation in social activities memory complex thinking self-care other

Please explain the changes

Income Information

Have you worked in the last 12 months?

Yes No

Has your employment/occupation changed in the last year?

Yes No

Do you expect your employment earnings to change in the current year?

Yes No

Earnings

Have you filed your taxes for last year?

Yes No

Have you received any benefits from any other workers' compensation boards in Canada or any other jurisdiction?

Yes No

Please provide any further information you feel may be relevant to your annual review. Thank you

Do you need additional space to provide more information

Yes No

Signature, consent and declaration

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.

By checking this box I declare that the information provided is true and correct. I consent to the release from any third party to the Workers' Safety and Compensation Board (board) of any medical, employment or other information relevant to my claim. I consent to the board disclosing to health care 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.

My name is/Signature

Date

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