WCB - Worker Report of Injury or Occupational Disease

Minimum Fields Error

In order to perform this operation, the following fields must be populated: Employer name, Worker Last Name, and Has the worker missed work (hours or days beyond the date of accident)

Error

Attention: Unable to proceed. The report contains invalid data.

Consent

Report of injury declaration and consent

To report an injury online, read the following declaration and consent statement and click the "I accept" button below.

I declare that the information I am about to provide to the Workers' Compensation Board - Alberta (WCB) in the 'Worker's Report of Injury or Occupational Disease' form will be true and correct.

I understand that:

While I am receiving any benefits from WCB, it is my obligation to inform WCB immediately if I return to work of any kind, become capable of working or if there is any other change in my employment status. Work includes but is not limited to any activity in which labour or services are provided, whether or not payment of any kind is received.
Criminal prosecution may result from any attempt on my part to collect benefits by providing false information, failing to provide information regarding my ability to work, or other fraudulent means.
My employer may request a review or appeal of any decisions made on my claim and may therefore examine my claim file. My claim file may also be examined by anyone with a direct interest, as determined by WCB, or a person or company I have authorized to review my claim file. (To provide authorization, use the Worker's Information Release form).
My social insurance number may be used for reporting to Canada Revenue Agency.
WCB may collect information that it considers relevant to determine benefit entitlement, including information pre-dating my accident, from any source including physicians, other health care providers, employer(s) and vocational rehabilitation service providers. This information is collected to determine my entitlement to compensation under the Workers' Compensation Act.
WCB may use and disclose the information collected to determine entitlement, to provide services and benefits and, as required or authorized by law. This information may be used and disclosed pursuant to the Workers' Compensation Act and the Freedom of Information and Protection of Privacy Act.

NOTE: The information required in the Worker's Report is collected under sections 33(a) and (c) of the Freedom of Information and Protection of Privacy Act for the purpose of determining entitlement to compensation and for determining employers' premium rates. Questions may be directed to the Claims Contact Centre.

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A possible match was found using Canada Post standards.
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Contact Centre

If you have general questions about your claim, you can email WCB Contact Centre using the form below. All fields with an asterisk (*) are required.

You can also speak to one of our Contact Centre representatives Monday to Friday from 8:00 a.m. to 4:30 p.m. by calling:

Tel: 780-498-3999
Toll free in Alberta: 1-866-922-9221
Toll free outside Alberta: 1-800-661-9608

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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Contact WCB

Please complete the fields below. Your message will be sent to WCB's eBusiness Support Team.

For inquires not related to online services, please use one of the contact methods described here.

Note: If you would like to add an attachment, please contact eBusiness.support@wcb.ab.ca directly.

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


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Submission Warning

Attention: This report contains one or more validation warnings. Please review the report or proceed with the submission.

Submission Error

Attention: This report contains at least one validation error. Please correct the error(s) and submit again.

Save Confirmation

Your report has been saved

Participant Details

Employer name:
Worker:		SIN:
Worker address:		Date of birth:

Employer Details
	*
	*
			*

Employer name:	*

LABEL NOT OVERRIDEN, UPDATE CHILD	*		*
LABEL NOT OVERRIDEN, UPDATE CHILD
City:	*	Province:
Postal code:
Phone number:	*

Contact name:	*	Contact title:	*
Contact phone number:	*	Contact email address:





	*
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:	*
Are you an apprentice?		* YesNo
		*
Do you have personal coverage?		* YesNo
Are you a partner or director in the business?		* YesNo

Accident Details

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

Date accident/injury reported to employer:	*
If more than 1 week since accident/injury, explain:	*
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 your name and claim number on the report. Please also complete the WCB Automobile Accident Report.
Is this a cardiac condition/injury? * YesNoUnknown
Were your actions at the time of the accident/injury...
For the purpose of your employer's business? * YesNoUnknown
Part of your regular work? * YesNoUnknown
Did the accident/injury occur on the employer's premises? * YesNoUnknown
Location of accident:	*
City:	*	Province/Territory:
Country:	*	Postal code:

	*
Have you reported or claimed this accident/injury to another WCB? * YesNo
Province/Territory:	*
When did you first seek medical treatment?
Name and location of treating doctor/hospital:	*
Is there any further treatment required for this injury? * YesNoUnknown

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

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

Hours and Shift Cycle Details
Average hours per week (not including overtime): *
Describe your work schedule (e.g. Monday to Friday, on. Saturday and Sunday, off.):	*