Employer's Report of Injury/Illness
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This information is being collected under the
authority of the Workers' Compensation Act for
the purpose of determining eligibility for benefits.
For further information, please call (867) 667-8796.
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Tell Us About Your Worker
To ensure we can process your claim quickly, please complete this form as
thoroughly as possible.
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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.
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Worker’s Mailing Address: |
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street, city, province or territory, postal code |
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What is the worker’s home address? |
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Date of birth:
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Yukon Workers' Compensation Health & Safety Board
