WCB - Employer Report of Injury

Tuesday July 21, 2026

Employer Report of Injury

Report Overview

Participant Details Accident Details Injury Details Return to Work Details Type of Employment Earnings Details Hours and Shift Cycle Details Other Information Submission Summary

Actions

ALERT: After 60 minutes of inactivity you will be logged out of your session and all information you've entered will be lost
NOTICE: You will have the option to Print a copy of this report at the time you submit it

Participant Details

Account number/name:
Worker:		SIN:
Worker address:		Date of birth:

Employer Details


Account number:		Employer name:
Industry:


Address line 1:		City:
Address line 2:		Province:

Postal code:
Phone number:	*	Fax number

Contact name:		Contact title:
Contact phone number:		Contact email address:
Use as modified work contact

Modified work contact name:
Modified work contact phone number:		Modified work contact email address:

Report completed by:
Worker Details
First name:		Middle name:
Last name:		Date of birth:

Mailing address:	City:
		Province:
Postal code:		Phone number:
Email address:

Alberta PHN:		SIN:
Legal gender:		Occupation:
Job description:
Date hired:
Is the worker an apprentice?		YesNo
Date the worker would have obtained journeyman status if they had not been injured:
Does the worker have personal coverage?		YesNo
Is the worker a partner or director in the business?		* YesNo

Accident Details

Injury Details

Part of body

Side of body

Nature of injury

If more than 5 parts of body, please describe any additional injuries:

Return to Work Details

I understand I have a duty to cooperate with WCB in coordinating a safe and healthy return to work for my injured worker.

Has the worker missed work (hours or days) beyond the date of accident?

YesNo

Will you pay the worker regular pay for the time missed from work?

YesNo

Date and time the worker first missed work:

Has the worker returned to work?

YesNo

Has modified work been offered to the worker?

YesNo

If you have a signed Offer of Modified Work Agreement, please mail, email, or fax it to us as soon as you have a claim number available. Please include the worker's name and claim number on the report.

Description of modified work:

Do you need assistance in identifying modified work opportunities?

YesNo

We can help you. Your case manager will be in touch to discuss safe modified work options with you and your injured worker.

Approximate date you expect the worker to return to work:

DateUnknown

Date and time the worker returned to work:

Is the worker working full hours?

YesNo

Hours worked per shift:

Is the worker working full duties or modified duties?

FullModified duties

Description of modified work:

Is the worker receiving regular/full pay or partial pay?

Regular/full payPartial pay

If modified work is required in the future, will it be available?

YesNo

Does the worker have more than one position within your business?

YesNo


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Earnings Details

Earnings contact name:

Earnings contact phone number:

Earnings contact email address:

Earnings information:

Gross Earnings InformationDetailed Earnings Information

Hourly rate of pay:

Does the worker take vacation as time off with pay?

YesNo

Vacation pay percentage:

Please enter the worker's gross earnings from:
- one year prior to the date of injury,
- or from the date the worker had a change in their wages in the past year,
- or from when they had a change in jobs in the past year,
- or from the date the worker was hired if less than 1 year from the date of injury.

Entering accurate earnings information is important because the workers compensation rate will be automatically set using these earnings. If accurate earnings are not available at this time, please submit the earnings as soon as possible.

If the worker receives shift premiums, overtime, or other taxable earnings not included in the hourly rate of pay, please enter these earnings in the section(s) below.

When providing these additional earnings, please enter the gross earnings one year prior to the date of injury,
- or from the date the worker had a change in their wages in the past year,
- or from when they had a change in jobs in the past year,
- or from the date the worker was hired if less than 1 year from the date of injury.

Entering accurate earnings information is important because the workers compensation rate will be automatically set using these earnings. If accurate earnings are not available at this time, please submit the earnings as soon as possible.

Gross earnings for the period:

From date:

To date:

Based on the information you have entered, the earnings are pro-rated to approximately <$#######.##> annually.

Was any time missed from work without pay (excluding vacation) during the above period? (E.g. Maternity leave, sick leave, WCB benefits, etc.)

YesNo

Provide dates and reasons:

	Gross earnings	Period start:	Period end:

Shift premium
Other taxable earnings
Overtime

Earnings Details

Hours and Shift Cycle Details

Shift cycle type:

Standard

Custom

Non-repeating

Shift cycle start date:

Average hours per week (not including overtime):

Shift cycle start date:

Number of days in shift cycle:

Please mark regular hours not including overtime for one complete shift cycle, use zero for days off.

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Week 11
Week 12
Week 13
	Note: Date of accident is highlighted in yellow.

Hours and Shift Cycle Details

Other Information

Claim number:

You may attach up to file attachments to this report of type: Doc, Docx, Tif/Tiff, Pdf, Rtf, or Txt

Additional comments:

NOTE: As required under subsections 4(a) and (c) of Alberta’s Protection of Privacy Act, the personal information collected in the Employer Report of Injury or Occupational Disease form is authorized by the Workers’ Compensation Act and is used for the purpose of determining entitlement to compensation and establishing employers’ premium rates. This information may also be processed by automated systems to generate content, recommendations, or predictions. Questions about the collection or use of this information may be directed to the Claims Contact Centre, as indicated below and on the back of the Employer Handbook.

P.O. Box 2415, Edmonton, Alberta T5J 2S5
Phone: 780-498-3999 (in Edmonton) 1-866-922-9221 (toll-free in Alberta) 1-800-661-9608 (outside Alberta)
Fax: 780-427-5863 or 1-800-661-1993

Please choose a file to upload:

Your report has been uploaded.

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Accident Details

Did the accident/injury develop over time? YesNoUnknown
Date/time of accident/injury:
Attention: If the exact date of accident is not known, please use the date the Worker first missed work as a result of this injury or the date it was first reported to the Employer.
Date/time scheduled shift started:		Date/time scheduled shift ended:

Date accident/injury reported to employer:
To whom was the accident/injury reported:
Name:		Title:
Phone number:
Description of accident/injury:
Is this a motor vehicle accident? YesNoUnknown
If you have a Police Collision Report, please mail, email, or fax it to us as soon as you have a claim number available. Please include the worker's name and claim number on the report.
Is this a cardiac condition/injury? YesNoUnknown
Were the worker's actions at the time of the accident/injury...
For the purpose of the business? YesNoUnknown
Part of the worker's regular work? YesNoUnknown
Did the accident/injury occur on the employer's premises? YesNoUnknown
Location of accident:
City:		Province/Territory:
Country:		Postal code:
Do you have any concerns affecting the acceptance of this claim? YesNo
Reason for concern:

Type of Employment
Please select the injured worker's specific employment type from one of the 3 groupings below: *

Employed on a Permanent basis (12 Months of the year or more) in the following arrangement:
Full Time Part Time Irregular/Casual

Or, employed on a Temporary basis (position is less than 12 months per year and may be subjected to layoffs due to lack of work, shut downs, contracts or seasonal factors) in the following arrangement:
SeasonalSummer StudentTemporary
Position start date:	Position end date:		EstimatedActual
Months or days per year workers are typically employed in this position:			MonthsDays

Or, employed in a Alternate arrangement that is most accurately described as:
Sub ContractorPiece WorkVehicle Owner/OperatorWelder Owner/Operator Self EmployedVolunteerCommissionOther
Please provide additional details:
Does the worker incur expenses?	YesNo	Will the worker receive a T4?	YesNo

Message subject:
Message:
	Please include any details, such as your claim number, that would help us serve you better.
Your e-mail address:


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E-mail address:
Message subject:
	Please include as much detail as possible.
Message:


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1) General Delivery Address JOHN JONES GD STN A CALGARY AB T0H 1A0	2) Post Office Box Address JOHN JONES PO BOX 4001 STN A VICTORIA BC V8X 3X4
3) Rural Route Address JOHN JONES SITE 6 COMP 10 RR 8 STN MAIN MILLARVILLE AB T0L 1K0	4) Civic Address JOHN JONES 10-123 1/2 MAIN ST SE MONTREAL QC H3Z 2Y7


Please select the best match found:
OR Use the address as entered