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
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Participant Details
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Account number/name:
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Worker:
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SIN:
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Worker address:
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Date of birth:
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Employer Details
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Account number:
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Employer name:
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Industry:
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Address line 1:
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City:
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Address line 2:
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Province:
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Postal code: |
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Phone number: |
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Fax number |
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Contact name:
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Contact title: |
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Contact phone number: |
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Contact email address: |
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Use as modified work contact
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Modified work contact name:
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Modified work contact phone number: |
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Modified work contact email address: |
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Report completed by:
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Worker Details
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First name:
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Middle name:
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Last name:
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Date of birth:
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Mailing address:
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City:
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Province:
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Postal code: |
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Phone number: |
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Email address: |
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Alberta PHN:
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SIN:
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Legal gender:
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Occupation:
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Job description:
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Date hired:
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Is the worker an apprentice?
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Date the worker would have obtained journeyman status if they had not been injured:
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Does the worker have personal coverage?
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Is the worker a partner or director in the business?
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| Accident Details |
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| Date/time of accident/injury: |
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| 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: |
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Date/time scheduled shift ended: |
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| Date accident/injury reported to employer: |
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| Name: |
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Title: |
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| Phone number: |
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| Description of accident/injury: |
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Is this a motor vehicle accident?
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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.
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Is this a cardiac condition/injury?
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| Were the worker's actions at the time of the accident/injury... |
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For the purpose of the business?
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Part of the worker's regular work?
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Did the accident/injury occur on the employer's premises?
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| Location of accident: |
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| City: |
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Province/Territory: |
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Postal code: |
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Do you have any concerns affecting the acceptance of this claim?
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| Reason for concern: |
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| Earnings Details |
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Earnings contact email address:
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Hourly rate of pay:
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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.
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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.
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Gross earnings for the period:
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| Based on the information you have entered, the earnings are pro-rated to approximately <$#######.##>
annually.
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Was any time missed from work without pay (excluding vacation) during the above period? (E.g. Maternity leave, sick leave, WCB benefits, etc.)
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Provide dates and reasons:
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| Hours and Shift Cycle Details |
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Shift cycle type:
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Shift cycle start date:
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Please mark regular hours not including overtime for one complete shift cycle, use zero for days off.
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