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Workplace Safety and Insurance Board (WSIB)

WSIB 101  |  Case Evaluation


 

  Name and address
 
  Phone Number
 
  E-mail
 
  What was the date of your accident?
 
  Who is your accident employer?
 
What parts of your body did you injure?

Neck
Head
Knee

Foot
Shoulder
Back

Hand / Wrist
Psychological
Exposure To Chemicals
Other:
 
Did you receive medical attention?
 		 Yes
 		 No
 
Has the WSIB paid any benefits?
 		 Yes
 		 No
 
Are you currently working?
 		 Yes
 		 No
 
Are you currently receiving...
WSIB Benefits
Sickness & Accident
CPP Disability
 
Have you received any retraining
from the WSIB?
 		 Yes
 		 No
 
If so, what program?

 
Do you currently have or had representation?
 		 Yes
 		 No
 
If so, whom?
Tell us about your WSIB problem in 100 words or less:

Submission of this form is not a retainer or agreement to represent you.

 
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