LGL232 assignment.docx EMPLOYMENT LAW WSIA ASSIGNMENT.docx

LGL232 assignment.docx
EMPLOYMENT LAW
WSIA ASSIGNMENT
DUE: March 23, 2015 (at the beginning of class via
Blackboard)
NAME: __________________________
TO DO:
1. Using the information that is contained in the Fact Scenario
below, complete Forms 6 and 7.
2. On a separate page attached to each of Form 6 and 7, provide
a typewritten analysis (no more than 1 page double spaced) of
the parties' positions concerning the entitlement to benefits. i.e.
Attached to Form 6 you will tell me the employee's reasons as
to why he is entitled to benefits; attached to Form 7 will be the
employer's arguments as to why the employee ought not receive
benefits in this case.
1. Do not make up any information.
2. Make sure that Form 7 is filled out within the proper time
frame and is indicated accordingly on the form. Pay attention to
the time frames - i.e. what information you would have known
as at the date the form is to be completed in a real life scenario.
3. Complete Form 6 as at March 23, 2015 to turn in with your
package, but try to do it before the Form 7 so you know what
you are responding to.

4. Turn in this assignment sheet together with your forms and
analyses through Blackboard.
FACT SCENARIO
Heathro Derotti (date of birth is November 1, 1958) is an
employee of Marvelous Digit
Supply Inc. (“Digit”). Digit is located at 83 Marshall Street,
Unit 9 in Toronto, M1R 8T7. Heathro started working at Digit
as a warehouse worker on February 1, 2005 and he has never
worked for anyone else during that time. He was promoted to
Junior Manager on August 1, 2008. His social insurance
number is 478 956 798. He resides at 758 Orchard Avenue,
Vaughan L8T 5K8.
On Wednesday February 4, 2015 at 8:45 a.m. Heathro was in his
office in the warehouse and was talking to a co-worker, Diego
Burns, a warehouse worker, about the upcoming PanAm Games.
Heathro and Diego, each with a hot cup of coffee in hand and
still enthusiastically discussing all things fencing, left Heathro's
office and were walking in the warehouse when they both saw a
pile of pens on a table. Diego grabbed a pen and said, “en
garde”, to which Heathro also picked up a pen and playfully
started to fence against each other. As they continued to attack
each other with the pens, their arms bumped, spilling hot coffee
on Heathro’s arm. Heathro lost his balance, fell against a steel
shelving unit and landed on the floor.
As Heathro lay on the floor, Diego saw blood gushing from
Heathro's cheek below his left eye. Heathro sat up and was
wincing and holding his left foot which had landed on when he
fell. Diego got a cloth and pressed it against the wound to try
and stop the bleeding and immediately called the Senior
Manager, Archibald Wagner, to come and assist.

Deigo received no injury whatsoever; curiously, his
strategically knotted man bun remained perfectly intact despite
the incident.
Archibald arranged for Heathro to go to a nearby walk-in clinic,
called 123 Medical Inc., by taxi. At the clinic, they did an x-
ray of his left foot, confirming that it wasn’t broken but was
only sprained. They wrapped his foot and gave him crutches.
They also performed an x-ray of his skull and confirmed that
there was no fracture. They stitched the gash under Heathro's
eye - 7 stitches in total. He was also diagnosed with a mild
concussion and first degree burns. He was prescribed Tylenol 3
with Codeine for pain and told to ice both his head and foot
every 2 hours. The clinic physician recommended that Heathro
see his own doctor early the following week for a checkup and
to begin physiotherapy. Heathro did go to physiotherapy on
Tuesdays and Thursdays starting February 16th until his return
to full time duties on March 9th.
Heathro did not return to work that day. However, based on his
doctor’s advice and discussions on Thursday February 12, 2015
with Archibald about returning to work, Heathro will return to
part time work on March 16, 2015. On that day he will go back
to his regular job, but will be working half days. They do not
want him back full time right away because of the concussion.
Heathro earns $20 per hour, and his normal work week before
the accident, was 8:30 a.m. to 5:30p.m. Monday to Friday, with
one hour for lunch between 12 p.m. and 1
p.m. He was not paid for his lunch hour. When he goes back
on March 16, 2015 he will work from 8:30 a.m. to 12 noon.
Heathro is expected to return to full working hours (his pre-
accident hours and schedule) commencing March 30, 2015.
Heathro has not received any pay since the accident.
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1906A (1).pdf
F O R M 6
W O R K E R ’ s R E p O R t
O f i n j u R y / d i s E a s E
R e F e R e n c e G u i d e F O R W O R K e R s
ENTER GUIDEPRINT GUIDE
F O R M 6 W O R K e R ’ s R e p O R t O F i n j u R y / d i
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R e F e R e n c e G u i d e F O R W O R K e R s
What To Do If You have An Accident at Work . . . . . . . .
. . . 3
General Information About The Form 6 . . . . . . . . . . . .
. . 5
The Worker’s Report of Injury/Disease (Form 6) . . . . . . .
. 6
Section A – Worker Information . . . . . . . . . . . . . . .
. 6
Section B – Employer Information . . . . . . . . . . . . . .
8

Section C – Accident/Illness Dates and Details . . . . 9
Section D – Health Care Information . . . . . . . . . . . 14
Section E – Lost Time & Return to Work . . . . . . . . 17
Section F – Earnings . . . . . . . . . . . . . . . . . . . .
. . 19
Section G – Declarations and Signature . . . . . . . . 20
WSIB Offices & Contact Numbers . . . . . . . . . . . Back
Cover
Table of Contents
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What To Do If You Have An
Accident at Work
What do I do if I get hurt or sick at work?
A worker who is injured at work or becomes sick
because of his/her job should:
1. Get first aid immediately, or health care if
needed.

2. Tell your employer about the accident or illness
as soon as possible.
How is the injury reported to the Workplace
Safety and Insurance Board (WSIB)?
Your employer is responsible, by law, to report
the accident or illness to the WSIB. That is why
it is important to tell your supervisor about the
incident or illness. The employer must complete
and submit a special WSIB form called the
Employer’s Report of Injury/Disease (Form 7).
There is a time limit for them to report so it is
important for you to let the employer know as
quickly as possible.
The employer is also required to do the
following:
pay you full wages for the day or shift the
accident/illness occurred, and
arrange and pay for transportation (on the day of
accident) to get you to health care, if needed, and
give you a copy of the Employer’s Report of
Injury/Disease (Form 7) once it is completed.
When can I make a claim for WSIB benefits?
As a worker, you can claim benefits for a work-
related accident or illness if you have:
received health care, and
lost time or wages from work beyond the day of

accident/illness, or
continued to work but on partial hours only.
If you had to do different work due to the accident/
illness for more than seven days and did not see a
health professional, you can also make a claim.
There is a time limit for you to report. It is
important to claim benefits as soon as possible.
You have six months from the date of the accident
to claim benefits or, for occupational diseases, from
the time you learn of the disease.
Do I always have to claim?
You do not have to make a claim if all four of the
following apply:
only first aid treatment was needed, and
you did not take any time off work, and
your pay was not affected, and
your job duties did not change.
How do I make a claim if I do not think my
employer has reported the accident/illness?
A worker can make a claim by calling the WSIB
General Number Toll Free at 1-800-387-0750 or
(416) 344-1000 and ask for assistance. One of our
representatives can help you.
A worker should also do one of the following:

complete, sign and submit a Worker’s Report of
Injury/Disease (Form 6) (See “How do I get this
form? on page 5) or
tell the health professional (chiropractor,
dentist, physician, physiotherapist or registered
nurse extended class) who first treats you that
the accident/illness is work-related so they can
complete and submit a Health Professional’s
Report (Form 8), or
visit your local WSIB Office – office locations are
found on the back cover of this document , or
contact your employer, or
if you have a union, ask them for help.
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What do WSIB benefits cover?
If you have an accident/illness at work, you may
be entitled to WSIB insurance benefits. The WSIB
insurance benefits may pay for:
health care to treat the injury/illness (for example
– physiotherapy, chiropractic treatment, etc…)

medications prescribed for your injury/illness
and
temporary income (wages lost while recovering).
Please note:
If your claim is approved, the wage loss benefit
pays you for time missed beginning after the day of
accident/illness. Your employer must pay your full
wages for the day of accident/illness.
What if I have to go to a health professional or
hospital because of the accident/illness?
1. Tell the person treating you that the injury
happened at work.
2. If you are ill and you think it was caused by
something at work, tell the person treating you:
when you first noticed the symptoms
what the work conditions are and how long
you have worked in these conditions.
3. The person treating you needs to complete
a WSIB report (Health Professional’s Report
– Form 8) and send it to the WSIB. On the form
there are places for you to give information
about yourself and your employer.
What about returning to work?
It may be possible for you to return to work while

you are in treatment and recovering. To help in
returning to work, you need to:
1. Participate fully in your treatment plan
2. Talk to your health professional about your
progress in treatment and about returning to
work
3. Stay in contact with your employer and keep
them up-to-date on your progress and
4. Talk with your employer about ways you can
return to work early and safely. This may include:
making temporary changes to your regular job
doing different work
working shorter or different hours or
any other options you and your employer may
come up with.
What to do if you think the WSIB has not been
notified?
We can tell you if the accident/illness was reported
or help establish a claim. Call us directly Toll Free
at 1-800-387-0750 or (416) 344-1000. If you are
hearing impaired call TTY 1-800-387-0050.
When should I claim?
It is important to claim benefits as soon as possible.

You have six months from the date of the accident
to claim benefits or, for occupational diseases, from
the start of the illness.
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General Information About The
Form 6
What is a Worker’s Report of Injury/Disease
(Form 6)?
Often called just the Form 6, this is a WSIB form
that the worker completes and sends to the
Workplace Safety and Insurance Board after a
work-related injury or illness.
It is a way for you to tell us the details of what
happened to cause the injury or illness. It also
provides us with information we need to make
decisions about and process your claim. This form
is different from the one you may have filled out at
work for your employer. When you complete and
submit the Form 6 it tells us that you are claiming
for benefits for a work-related accident.
When should I complete this form?
You should complete, sign and return this form as

soon as possible following a work related injury/
awareness of illness. It’s best to complete this form
soon after the accident or awareness of illness –
while all the details are still fresh in your memory.
There is a deadline. A claim must be filed within
six months of an accident or, in the case of an
occupational disease, within six months of a
worker learning of the disease. The claim may
be filed after six months, if the worker can show
“exceptional circumstances” existed at the time of
the deadline. For further information, call
1-800-387-5540.
How do I get this form?
There are several ways that you can get this form.
when the WSIB establishes your claim from the
employer’s or health professional’s report, we will
mail a Worker’s Report to you
your local union office/representative may have
one to give you
you can print one off the WSIB website at
www.wsib.on.ca (Forms Tab – Workers) or
call or drop by your local WSIB office to ask for a
Form 6 – Worker’s Report of Injury/Disease.
If you have completed a Form 6 and sent it to us,
and then you receive one in the mail, call us to
make sure that we have received and recorded the
original. If we can confirm that we have it, then
you don’t have to complete it again. In fact, we

prefer that you don’t send in two, because it can be
confusing.
What if I need help to complete the Form 6?
If you need help or cannot complete the Form
6 yourself, we suggest that first you ask a family
member or friend to help you. Or, you can also
contact us directly Toll Free at 1-800-387-0750
or (416) 344-1000. We can assist you in many
languages. For help in another language call
1-800-465-5606. If you are deaf or hard of hearing,
call TTY: 1-800-387-0050.
What do I do after completing the Form 6?
Sign and date it
Send a copy to the Workplace Safety and
Insurance Board (WSIB)
Mail: Workplace Safety and Insurance Board
200 Front Street West
Toronto ON M5V 3J1
OR
Fax: Local: (416) 344-4684
Toll-Free 1-888-313-7373
OR
Drop it off to your local WSIB Office. Locations
are listed on the back cover of this guide.
Remember to:

Provide a copy to your employer
Keep a copy for your own records
Please print clearly in black ink.
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a1
Date you started with employer
Give us the date that you started to work
with your employer. If you worked for them
in the past, (you may be a temporary or
seasonal worker), give us the most recent
(latest) date that you started to work with
this employer.
a1
Section A – Worker Information
This information is important to set up your claim accurately.
Please make sure all information is complete
and correct. Incorrect information may cause delays in handling
your claim. Include your:
full name
complete mailing address

phone number
date of birth and
Social Insurance Number
Please note that your Name and
Social Insurance Number must
appear on all 3 pages.
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a2
How long have you been doing this job
for this employer?
Give the length of time (in years, months,
weeks or days) that you have been doing the
job that you were hurt at.
Example:
You have worked for ABC Company for 6
years, first as shipper/receiver for two years,
then as warehouse lead hand for one year,
then as warehouse manager for three years.
You were the manager when injured, so

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put the length of time you have been the
manager (three years).
a�
Would an interpreter be useful?
yes no
The WSIB provides translation and
interpretation services in several languages to
help you communicate with WSIB staff. The
service is at no cost to you. To ask for help in
another language call 1-800-465-5606.
a�
Do you authorize your union to represent
you in this claim?
yes no
If you are a member of a union, you may
want to contact them to help you with this
claim. If you do, please check ‘yes’ here.
a�
If yes, do you consent to the disclosure
of verbal claim file status information to

your union representative?
yes no
This means you agree to let the WSIB
talk about your claim with your union
representative. If you do want your union to
help you with this claim, check ‘yes’ here so
we can talk to them about the status of your
claim. If your union representative wants
access to written material in your claim, they
must send us written authorization that you
have chosen them to represent you.
If you choose a representative who is not
from your union, you will need to provide
written authorization for the exchange of
any information.
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Section B – Employer Information
This section provides us with information about your employer.
We need all the information requested. We
will use this information to process your claim and contact your
employer if necessary.
If you need to, check your pay stub for the correct employer
information, including the full Company

Name.
If you work for a Temporary Employment Agency, in this
section please give us the name of the agency
who sent you to the job, not the name of the worksite employer.
You can give us the location information
in the next section.
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Section C – Accident/Illness Dates and Details
This section provides with the details about your
accident/illness.
c1
Date and hour of accident/Awareness of
illness
If the accident happened suddenly (for
example – you slipped on wet floor and
twisted your left ankle), give us the date and
time the accident occurred.
If the accident did not happen suddenly, but
your injury occurred over a period of time
(for example – as a cashier, you developed
tennis elbow because of scanning groceries)
give us the approximate date you first started

to notice it.
c2
Date and hour reported to employer
Give us the date and time you first told your
employer about the injury/illness. Remember
it is important to let them know right away.
c3
Who did you report this accident/
illness to?
(Name & Position and Telephone)
You should report your accident/illness,
as soon as possible, to your employer.
This should be your supervisor, manager,
company nurse, or other person your
employer has specified. Give the name,
position and telephone number of that
person.
c4
Area of Injury (Body Part)
(Please check all that apply)
Check (√) all of the body parts you may have
hurt as a result of this accident/illness. If it is
not listed here, check (√) “Other” and give us
a written description. Remember to indicate
the left or right side of the body.

Also check (√) if you are left-handed or
right-handed. This useful information can be
helpful in getting you back to work.
c5
Did the accident/illness happen on the
employer’s property or work site?
yes no
Specify where it happened (shop floor, warehouse,
client/customer site, parking lot, etc.)
Your accident/illness may or may not have
happened on your employer’s property
or worksite. If it did, check (√) ‘yes’ and
tell us where it happened on the premises
(for example – shipping area, paint shop,
assembly line three, etc…)
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Section C – Accident/Illness Dates and Details continued…
c6
c8c7
If no, please tell us the location.
Examples:
you may work for a cleaning company
and are assigned to do cleaning work
at a large retail store, where the injury
happened, then you would name that
store and its location
you may work away from a central office/
area and are visiting a client site, name the
client site and location here
you may work for a temporary
employment agency, and this is where
you would put the name of the company
where you are placed.
c6
Did it happen outside the Province of
Ontario?
yes no
If yes, indicate where (city, province/state, country)

Check ‘yes’ if the accident/illness occurred
outside of Ontario. If yes, you may have the
choice of claiming benefits either in Ontario
or in that other jurisdiction.
The answer ‘yes’ prompts the WSIB to send
you a form so you can choose where you will
claim benefits. This is called an election form
and it will help avoid potential delays. If you
are claiming in Ontario you must say so on
the election form. Without this information,
we can establish a claim but we cannot
make any decision about benefits until we
receive and approve the election form. You
have three months from the date of issue to
submit the election form.
Example:
A truck driver who lives in Ontario but
travels across provincial borders has a motor
vehicle incident in Manitoba. The worker
has the choice to claim in Manitoba or
Ontario.
c7
Have you hurt this/these area(s) of your
body before?
yes no
Check ‘yes’ here if you have hurt an area
of your body before. It does not mean that

we will deny your claim, but it will help
us find earlier records that may assist with
processing your claim. As well, it may reduce
the costs of the claim for your current
employer.
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c�
Do you have any prior related WSIB/
WCB claims?
no
yes – In Ontario yes – Outside Ontario
Check ‘yes’ here if you have had a prior
claim, in Ontario or elsewhere, for the same
area of injury. This helps us to determine
if this may be a re-injury under that prior
claim.
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c9
If you had a sudden type of accident/
illness, describe your injury…
Give us the full details of how the accident/
illness happened and what you were doing
when it occurred. Be sure to include: sizes,
weights and names of object involved,
a description of any machinery, tools or
vehicles used at the time of accident/illness,
any environmental conditions (work area,
temperature, noise, chemicals, gas, fumes,
other person) or any other information you
think is important.
c9
Example:
I was moving boxes in the storage room. I
lifted a 40 lb box from the floor to place on a
shelf. I twisted to the right while lifting, and
hurt my upper back.
OR
If you had a gradual onset type of injury,
describe your injury…
If your injury/illness developed over a period

of time, please provide a detailed description
of the work you do. Give details about the:
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frequency of activities (how often you do
this task)
the sizes and weights involved
how long you have been doing this work
if there are any recent changes to the
work or the workplace
any changes to your work schedule and
tools or products you use to do this work.
Example:

I am a cashier. I continually scan products
for my entire 6 hour shift using my left arm.
The products weigh from a few ounces to up
to 10 lbs. The belt has been malfunctioning
over the past three weeks forcing me to reach
further that I usually do for the products. I
recently started to experience pain in my left
elbow.
c10
When did you first start to have
problems with this injury/condition?
WSIB may use this information to help
determine a day of accident/illness, especially
for injuries that developed over a period of
time.
c11
If you did not report this to your
employer right away, please tell us the
reason why.
You should report accidents/illnesses right
away. There may be a reason why you did not
report right away and we need to know the
reason.
c12
If there were any witnesses to your
accident…
This information is used to get a fuller

understanding of the accident/illness.
Provide the names and positions of any co-
workers that you told about the accident, the
pain you feel, or who may have seen what
happened. The WSIB may need to contact
them for further information.
c1�
The Workplace Safety and Insurance Act
requires your employer to give you a
copy of the Employer’s Report of Injury/
Disease (Form 7).
Did you receive a copy of the Form 7?
yes no
You should have received a copy of the
Employer’s Report of Injury/Disease (Form
7) from your employer. If you did not, ask
them for your copy.
The Workplace Safety and Insurance Act
requires you to give a copy of this report
(Worker’s Report of Injury/Disease –
Form 6) to your employer.
Just like your employer must provide you
with a copy of their report, you are also
required to give your employer a copy of
your report (Form 6). The information you
provide may help them in their accident
investigation and prevent this type accident
from happening again.

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Section D – Health Care Information
This section gives us information on any health care you
received for your injury/illness. If you get health
care treatment, you must tell the person treating you that the
injury happened at work. The health
professional (chiropractor, dentist, physician, physiotherapist or
registered nurse extended class) treating
you will then need to complete a report and send it to the WSIB
so you can claim benefits. Most health
professionals keep copies of the Health Professional’s Report
(form 8) in their office or, they can print one
from our web site.
To ensure that we receive their reports in a timely way, please
tell the person treating you that this accident/
illness is work-related. The WSIB may also request reports
directly from health professionals.
As soon as you know your claim number, please give it to the
health professional treating you.
Remember, on the day of accident, the employer is responsible
to pay for transportation to get you to
health care, if needed.

D1
Did you get first aid or care at work?
yes no If yes, when and by whom…
First aid refers to any care provided to a
worker that could be given by a trained
first-aider (e.g. washing a wound, applying a
dressing, etc…) even if done by an in-house
health professional.
Check ‘yes’ here if someone treated you at
work for your injury/illness. Give us the date
when you were treated and the name (or title
– as indicated in example) of the person who
treated you at work.
Example:
yes 23/03/05, company nurse
D2
Where did you go for health care, for
your injury, outside of work?
(Check all that apply)
Health care refers to any professional
services provided by anyone of the following
registered health care professionals
(chiropractor, physician, physiotherapist,
registered nurse extended class or dentist).
This health care can be at a hospital or other
facility (emergency department, walk-in
clinic, health professional office, etc…) or the

worksite.
Check (√) all the places that you went for
health care outside of work.
D1
D2
D3 D4
D5
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Nursing Station
This is a facility that is not part of a hospital,
usually found in smaller communities.
Emergency Department
This may be part of a hospital or in a
specialized emergency facility outside of a
hospital.
Admitted to Hospital
Check this only if you were admitted to a

hospital for an overnight stay.
Ambulance
Check this if a paramedic treated you.
Health Professional Office
Many health professionals have their own
private practice and this refers to that health
professional’s independent office. This
includes a:
chiropractor
physician
physiotherapist
registered nurse extended practice or
dentist.
Clinic
This refers to a walk-in clinic or a facility
where several health professionals provide
health care.
For Nursing Station, Emergency Department
and Admitted to Hospital, please give us their
name and address as well as the date of visit.
For Ambulance, Health Professional Office, and
Clinic, please give us the date of visit only.

d�
Were you prescribed any medications/
drugs?
yes no
Please check (√) whether you were given any
medication/drugs for your injury/illness. We
may pay for medications/drugs prescribed
as a result of the accident/illness. You do not
need to give the name of the medications/
drugs.
d�
Were you referred for any other
treatment or tests?
yes no
Check (√) here whether you were referred for
any other treatment (example: physiotherapy,
chiropractic, massage, acupuncture), or tests
(example: MRI, CT Scan, X-ray, bone scan,
etc.).
d�
Did you talk to your health professional
about going back to regular or modified
work?
yes no
If yes, were you given any work limitations?

yes no
Take the opportunity to talk to your health
professional about a return to work. Your
health professional may provide you with
work/task limitations for this, which will
help guide you and your employer in your
return to work. You have an obligation to
tell your employer if you have been provided
with any limitations.
You can share these limitations with your
employer by having the health professional
complete a:
return to work note or
by giving the health professional a
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6
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“Functional Abilities Form for Timely
Return to Work” form which can be given
to you by your employer, your union or
WSIB office.
Your employer may be able to accommodate

you with work based on your work/task
limitations.
D6
Did you tell your employer you went for
medical treatment?
yes no
If yes, when (date field)
and to whom? (Name, Position)
If no, please tell your employer right away.
You must tell your employer that you went
for medical treatment for your injury. If your
employer has not already done so, they will
need to complete an Employer’s Report of
Injury/Disease (Form 7) and submit it to the
WSIB. Please provide the date when you told
your employer that you went for medical
treatment.
If you have not told your employer that you
went for medical treatment, please tell them
right away.
Section D – Health Care Information continued…
D6
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Section E – Lost Time & Return to Work
This section gives us information on whether or not you have
lost time and/or pay because of your
accident/illness. If you did lose time and have already returned
to work, we need information about your
return to work. If you have not returned to work, you need to
contact your employer to discuss it.
The employer is responsible to pay you your full wages for the
day of accident/illness.
E1
After the day of accident/illness:
I returned to work to my regular job and did not
lose any time or pay.
Check (√) this box if you returned to work
on your next regularly scheduled shift and
you returned to your normal work duties
with no changes and you did not miss any
time from work or suffered any reduction in
your earnings.
I returned to modified duties and did not lose
any time or pay.
Check (√) this box if you returned to work
on your next regularly scheduled shift and
you returned to modified work duties and

you did not miss any time from work or
suffer any reduction in your earnings.
Modified duties may be any change or
accommodation to your work or the
workplace.
I lost time and/or pay (e.g. regular pay, shift
differential, bonuses, premiums, etc.).
Check (√) this box if you missed any time
from work or suffered any reduction in your
earnings or if your employer paid you while
you were off work.
This lost time may be for a partial day or an
entire day or more. This includes time taken
for a medical appointment or health care
treatment for your injury/illness.
Date you first lost time and/or pay.
Give us the first date that you either missed
time or that you had a loss of earnings.
E1
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E2
If you lost time, have you returned to
work?
Check ‘yes’ if you have lost time but have
since returned to work.
If yes > Date of your return to work
regular work modified work
Provide the date you returned to work and
whether you returned to your regular work
or to modified work.
Check ‘no’ if you have not yet returned to
work.
E3
Did you discuss return to work with your
employer?
yes no
A worker is required to take an active part in
the return-to-work process. This means that
you are required to stay in touch with your
employer and discuss your safe return to
regular or modified work.
Discussing return to work gives you a chance
to talk about any concerns or worries you
have with your employer about your return

to work, especially if you have been provided
with work/task limitations by your health
professional. It also gives your employer
a chance to discuss the set up of modified
work with you, if necessary.
Section E – Lost Time & Return to Work continued…
E4
Does your employer have modified
work?
yes no
It is your responsibility to call your employer
to find out if they have work that you can do
while you are recovering.
If, after you complete and send us this report,
there is any change in the information that
you gave us in this section, please call your
adjudicator right away and let them know
what has changed.
E2
E3 E4
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TABLE OF CONTENTS
Section F – Earnings (Do not include overtime here)
This section provides basic information about your earnings.
This information may be used by the WSIB
when paying benefits for lost time from work due to your
injury.
F1 Rate of Pay:
Indicate how much you get paid by the
hour if you are paid hourly, weekly if paid
weekly, or “Other” if pay is based on salary,
commission, piecework, etc… If you choose
“Other”, please indicate the type of pay.
F2
Usual number of pay hours:
Provide the usual number of hours you work
per week.
F3
If you lost time from work after the
day of accident/illness, did your
employer continue to pay you?
yes no
If you lost time from work due to your
injury, your employer may have continued to
pay you for the lost time from work. Please
check (√) ‘yes’ if your employer continued to
pay you while you were off work.

F4
Have you applied for, or did you receive,
any other benefits (money) while off
work…
yes no
You must advise the WSIB if you have
applied for, or are receiving, any other
benefits as a result of your injury and/or lost
time from work.
F5
At the time of the accident/illness did
you work for more than one employer?
yes no
Check ‘yes’ if you worked for more than one
employer at the time of your accident. This
information is important when calculating
what the WSIB will pay you.
F1
F2
F3
F4
F5

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Section G – Declarations and Signature
When you sign this form, it tells the WSIB that
you are claiming benefits for your work-related
injury/illness and that you are declaring that all
information you have provided on each page of
this form is true. If you do not sign the form it
could delay your benefits.
By signing, you are also allowing the health
professional treating you to provide you, your
employer and the WSIB with information about
your functional abilities that can be used to help
get you safely back to work. This information can
be requested by either you or your employer by
using the WSIB’s “Functional Abilities Form for
Planning Early and Safe Return to Work.”
Your privacy is important to us. You can get a
Privacy Statement from the WSIB website at
www.wsib.on.ca or by calling your adjudicator at
1-800-387-5540.
Please sign and date the form and forward it to
the WSIB either by fax or by mail. Be sure to keep
a copy for your records and to also give a copy of

the completed form to your employer.
Toronto, ON M5V 3J1
Fax: Local: (416) 344-4684
Toll-Free 1-888-313-7373
s e a s e
R e F e R e n c e G u i d e F O R W O R K e R s p a G e 2 1
TABLE OF CONTENTS
Notes
s E a s E
1906A (08/07) © 2005, Workplace Safety & Insurance Board.
Printed in Canada.
WSIB Offices
Guelph
Phone: 519-826-4650
Toll Free: 1-888-259-4228
hamIltOn

Phone: 905-523-1800
Toll Free: 1-800-263-8488
KInGStOn
Phone: 613-544-9682
Toll Free: 1-800-267-9461
KItchener
Phone: 519-576-4130
Toll Free: 1-800-265-2570
lOndOn
Phone: 519-663-2331
Toll Free: 1-800-265-4752
nOrth Bay
Phone: 705-472-5200
Toll Free: 1-800-461-9521
OttaWa
Phone: 613-237-8840
Toll Free: 1-800-267-9601
Sault Ste. marIe
Phone: 705-942-3002
Toll Free: 1-800-461-6005
St. catharIneS
Phone: 905-687-8622
Toll Free: 1-800-263-2484
SudBury
Phone: 705-675-9301
Toll Free: 1-800-461-3350
thunder Bay

Phone: 807-343-1710
Toll Free: 1-800-465-3934
tImmInS
Phone: 705-235-6130
Toll Free: 1-800-461-9856
tOrOntO (appealS Branch)
Phone: 416-344-1014
Toll Free: 1-800-387-0773
tOrOntO
Phone: 416-344-1000
Fax: 416-344-4684
Teletypewriter: 1-800-387-0050
Toll Free: 1-800-387-0080
Ontario Toll Free: 1-800-387-0750
WIndSOr
Phone: 519-966-0660
Toll Free: 1-800-265-7380
taBle OF cOntentS
Table of ContentsWhat To Do If You Have An Accident at
WorkWhat do I do if I get hurt or sick at work?How is the
injury reported to the Workplace Safety and Insurance Board
(WSIB)?The employer is also required to do the
following:When can I make a claim for WSIB benefits?Do I
always have to claim?How do I make a claim if I do not think
my employer has reported the accident/illness?What do WSIB
benefits cover?What if I have to go to a health professional or
hospital because of the accident/illness?What about returning to
work?What to do if you think the WSIB has not been
notified?When should I claim?General Information About The
Form 6What is a Worker’s Report of Injury/Disease (Form
6)?When should I complete this form?How do I get this

form?What if I need help to complete the Form 6?What do I do
after completing the Form 6?Section A – Worker
InformationDate you started with employerHow long have you
been doing this job for this employer?Would an interpreter be
useful?Do you authorize your union to represent you in this
claim?If yes, do you consent to the disclosure of verbal claim
file status information to your union representative?Section B –
Employer InformationSection C – Accident/Illness Dates and
DetailsDate and hour of accident/Awareness of illnessDate and
hour reported to employerWho did you report this accident/
illness to?Area of Injury (Body Part)Did the accident/illness
happen on the employer’s property or work site?Did it happen
outside the Province of Ontario?Have you hurt this/these area(s)
of your body before?Do you have any prior related WSIB/ WCB
claims?If you had a sudden type of accident/ illness, describe
your injury…If you had a gradual onset type of injury, describe
your injury…When did you first start to have problems with this
injury/condition?If you did not report this to your employer
right away, please tell us the reason why.If there were any
witnesses to your accident…The Workplace Safety and
Insurance Act requires your employer to give you a copy of the
Employer’s Report of Injury/ Disease (Form 7).The Workplace
Safety and Insurance Act requires you to give a copy of this
report (Worker’s Report of Injury/Disease – Form 6) to your
employer.Section D – Health Care InformationWhere did you go
for health care, for your injury, outside of work?Health
careNursing StationEmergency DepartmentAdmitted to
HospitalAmbulanceHealth Professional OfficeClinicDid you get
first aid or care at work?First aidWere you prescribed any
medications/ drugs?Were you referred for any other treatment or
tests?Did you talk to your health professional about going back
to regular or modified work?Did you tell your employer you
went for medical treatment?Section E – Lost Time & Return to
WorkAfter the day of accident/illness:I returned to work to my
regular job and did not lose any time or pay.I returned to
modified duties and did not lose any time or pay.I lost time

and/or pay (e.g. regular pay, shift differential, bonuses,
premiums, etc.).Date you first lost time and/or pay.If you lost
time, have you returned to work?Did you discuss return to work
with your employer?Does your employer have modified
work?Section F – Earnings (Do not include overtime here)Rate
of Pay:Usual number of pay hours:If you lost time from work
after the day of accident/illness, did your employer continue to
pay you?Have you applied for, or did you receive, any other
benefits (money) while off work…At the time of the
accident/illness did you work for more than one
employer?Section G – Declarations and SignatureWSIB Offices
PRINT:
1907A (1).pdf
ENTER GUIDEPRINT GUIDE
F O R M 7
E M P L O Y E R ’ S R E P O R T
O F I N J U R Y / D I S E A S E
R E F E R E N C E G U I D E F O R E M P L O Y E R S
F O R M 7 E M P L O Y E R ’ S R E P O R T O F I N J U R
Y / D I S E A S E
R E F E R E N C E G U I D E F O R E M P L O Y E R S
Overview of Employer Reporting Obligations . . . . . . . . . . . . 3
Heading Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section A – Worker InformationSection A – Worker
InformationSection A . . . . . . . . . . . . . . . . . . 6

Section B – Employer Information. . . . . . . . . . . . . . . . 9
Section C – Accident/Illness Dates and Details. . . . . 12
Section D – Health Care. . . . . . . . . . . . . . . . . . . . . . 18
Section E – Lost Time – No Lost Time . . . . . . . . . . . . 20
Section F – Return to WorkSection F – Return to WorkSection
F . . . . . . . . . . . . . . . . . . . . 22
Section G – Base/Wage/Employment Information . . 24
Section H – Additional Wage Information . . . . . . . . . 29
Section I – Work Schedule . . . . . . . . . . . . . . . . . . . . 32
Section J – Employer Declaration . . . . . . . . . . . . . . . 34
WSIB Offi ces & Contact Numbers . . . . . . . . . . . . . Back
Cover
Table of Contents
Y / D I S E A S E
R E F E R E N C E G U I D E F O R E M P L O Y E R S P A
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TABLE OF CONTENTS
Overview of Employer Reporting

Obligations
When should I complete this report? What is
my reporting obligation?
Employers must report a work related accident/
illness to the Workplace Safety and Insurance
Board (WSIB) if they learn that a worker requires
health care and/or:
is absent from regular work
earns less than regular pay for regular work (e.g.,
only working partial hours)
requires modifi ed work at less than regular pay
Reporting is also required if, following the date of
the work related accident/illness, the worker does
not receive health care but requires modifi ed work
at regular pay for more than seven calendar days.
After fi lling out this form, please sign it, date
it, and:
1. send a copy to the Workplace Safety and
Insurance Board (WSIB) by mail or fax,
2. provide a copy to the worker (this includes all
attachments), and
3. keep a copy for your records.
Consequences of not meeting your reporting
obligations

The WSIB will charge a penalty of $250 for each of
the following:
late submission of this report,
incomplete information,
failing to provide a copy of the completed Form
7 to the worker, and
reporting on a version of this form that the WSIB
has not approved.
These can be multiple fi nes. For example: If the
Form 7 is submitted late and incomplete, the fi ne
would be $500.
Individuals may be liable, on conviction, to a
fi ne of up to $25,000 or up to 6 months in jail. A
corporate entity, if convicted, may be fi ned up to
$100,000.
The employer is required to take every reasonable
eff ort possible to obtain the information requested
on the Form 7 and complete and submit it within
the allotted time period. If complete information
is not possible to obtain within the allotted
time period, submit the Form 7 along with an
explanation of what is missing and what is being
done to obtain it.
How quickly should this report be sent to the
WSIB?
The law requires you to complete this form within
3 calendar days after learning of your reporting

obligation as a result of a work related accident/
illness. The completed form has to be received
by the WSIB within 7 business days after you
learn of your reporting obligation. Do not delay
completing and sending the form to the WSIB in
Toronto. Send the completed Form 7 by mail or fax
to:
Toronto, ON M5V 3J1
Fax: Local: (416) 344-4684
Toll-Free 1-888-313-7373
What does WSIB consider health care?
Health care includes:
services provided at hospitals and health facilities
and
services that can only be provided by one of the
following health care professionals: chiropractor,
physician, physiotherapist, registered nurse
(extended class), or dentist.
You should complete this report if dentures, glasses
and/or artifi cial appliances (e.g., prosthetic arm)
were damaged while being worn in a work related
accident.
Y / D I S E A S E

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TABLE OF CONTENTS
What does WSIB consider fi rst aid?
First aid is the one-time treatment or care and any
follow-up visit(s) for observation purposes only.
First aid includes, but is not limited to:
cleaning minor cuts, scrapes, or scratches
treating a minor burn
applying bandages and/or dressings
applying a cold compress, cold pack, or ice bag
applying a splint
changing a bandage or a dressing after a follow-
up observation visit.
Do I have to report fi rst aid treatment?
It is not necessary to complete this report for fi rst-
aid-only injuries handled by an in-house/worksite
health care professional or trained fi rst-aider.
However, the law requires that you must keep a
record of all fi rst aid details.
On the day of accident the employer must:
1. provide and pay for immediate transportation

to a hospital, health professional offi ce/clinic or
the worker’s home (if necessary) and
2. pay for full wages and benefi ts for the day or
shift on which the injury occurred.
Need help with this form?
If you need assistance in completing this form,
contact your:
Account Manager or Customer Service
Representative
Adjudicator.
A complete list of contact numbers for all WSIB
offi ces is on the back cover of this guide.
The Offi ce of the Employer Adviser is also available
to provide assistance. You can contact them directly,
toll-free at 1-800-387-0774.
Y / D I S E A S E
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TABLE OF CONTENTS
Heading Area
1 WSIB Mailing Address/FAX Numbers

All claims are established through the
Toronto offi ce of the Workplace Safety and
Insurance Board. To avoid delays, fax or mail
completed Form 7s to the Toronto Offi ce.
Toronto ON M5V 3J1
Fax: Local: (416) 344-4684
Toll-Free 1-888-313-7373
2 Claim Number
Once the claim is established, the WSIB will
send the employer the claim number. If the
employer already has the claim number
when completing the Form 7, it should be
included on all pages.
If you include attachments to the Form 7,
write the worker’s name and claim number
(if known) on all pages.
3 Please PRINT in black ink
If you complete the Form 7 by hand, please
print neatly and use black ink. As most forms
are faxed, printing in black ink makes them
easier to read.
4 Worker Name, Claim Number, Social
Insurance Number
On the top of each page, you will fi nd a

space to provide the worker’s name, social
insurance number and claim number (if
known). Please provide it here as this helps
to make sure the pages remain together as
they are processed.
1
2
3
4
Y / D I S E A S E
G E 6
TABLE OF CONTENTS
Section A – Worker Information
This information is required to establish the worker’s claim.
A1 Worker Name and Address (number,
street, apt., suite, unit), City/Town,
Province, Postal Code, Telephone
Give the worker’s complete name, last name
followed by fi rst name and their current, and
complete home address.
This information is placed so it can be seen
in the window of an envelope. This will

make it easier for you to mail a copy to the
worker.
A2 Social Insurance Number
The worker’s 9-digit social insurance
number is required to meet WSIB reporting
obligations and requesting it is authorized
under the Income Tax Act.
A3 Date of Birth
Give the worker’s date of birth.
Date/Month/Year DD/MM/YY.
Example:
26/01/59
A4 Job Title/Occupation
(at the time of accident/illness – do not use
abbreviations)
Give the worker’s job at the time the
accident/illness occurred. Give us the name
of the job the worker was doing when
injured, even though it may not be the
worker’s regular job.
Example:
Normally Linda is a welder, but was
temporarily working as a shipper/receiver in
the warehouse when injured.

In this case you would give the job title of
shipper/receiver.
A5 Length of time in this position while
working for you
Give the length of time (in years, months or
weeks) that the worker has been performing
the job he/she was injured at.
A1
A2
A3
A4 A5
A6
A7
Y / D I S E A S E
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TABLE OF CONTENTS
Example:
The worker may have been employed by
your fi rm for 7 years, but, at the time of

injury, the worker had only been doing that
job for 2 years, then answer 2 years.
A6 Date of Hire
Give the date the worker became an
employee of your fi rm. If the worker has
been hired in the past, (e.g. seasonal or
temporary worker), provide the most recent
date of hire.
A7 Please check if worker is a:
executive elected offi cial owner
spouse or relative of the employer
This will not apply to most workers.
However, you should know that to be
covered in case of injury/illness under the
Workplace Safety and Insurance Act, these
people would likely need to have optional
insurance. If you are unsure of the status,
check the one you think is correct and the
adjudicator will follow-up with you. Do not
delay sending in the form even if you are
unsure.
Defi nitions
Executive – This is an individual who:
has been delegated the authority to
act independently on behalf of the
organization;
is responsible for the overall direction and

control of the company’s operations or
fi nancial aff airs;
exercises a broad scope of authority to
make decisions or formulate policies for
the organization as a whole, rather than
the authority that is strictly limited to a
specifi c branch or division; and
has the ability to bind the organization.
These may include anyone of the members
of the Board of Directors, including the
position of Chair, Vice-Chair, President,
Vice-Presidents and Chief Executive Offi cers,
Corporate Secretary, Treasurer, or Director
in a limited company, or General Manager
or Manager designated an offi cer by by-
law or resolution of the Directors. (For
more detailed information about Executive
Offi cers, please refer to WSIB Operational
Policy 12-03-03. The WSIB Operational
Policy Manual can be found at the WSIB
website at www.wsib.on.ca)
Elected Offi cial – This is an individual who:
has been elected to the position;
has been temporarily appointed to an
elected position;
is a member of the governing board,
either appointed or elected;
or the equivalent thereof.

(For more detailed information about
Elected Offi cial, please refer to WSIB
Operational Policy 12-03-03. The WSIB
Operational Policy Manual can be found on
the WSIB website at www.wsib.on.ca)
Owner – This is an individual who is listed Owner – This is an
individual who is listed Owner
as the owner/proprietor of the business.
Spouse or Relative of the Employer – This Spouse or Relative
of the Employer – This Spouse or Relative of the Employer
is an individual who may be listed as an
Executive Offi cer. For further information or
clarifi cation, contact your Account Manager
or Customer Service Representative.
Y / D I S E A S E
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TABLE OF CONTENTS
Section A – Worker Information continued…
A8 Worker Reference Number
The employer may wish to record the fi rm’s
employee identifi cation number (e.g., the
worker’s payroll number) in this space. The
WSIB does not require this number. It is here

for the employer’s own internal tracking
purposes.
Mining companies, including contractors
doing mining work, may enter the worker’s
Miner’s Certifi cate Number here.Miner’s Certifi cate Number
here.Miner’s Certifi cate Number
A9 Sex – M F
Check (√) M (male) or F (female).
A10 Is the worker covered by a Union
Collective Agreement?
yes no
Check ‘yes’ if this worker is a member of
a recognized union/association that has a
negotiated collective agreement with your
fi rm. The name/local is not required now. We
will request it if needed.
A9
A10
A11
A11 Worker’s preferred language
English French Other ____________
Check (√) which language preference applies
to this worker. Unless you indicate that the
worker prefers French services, all services

will be provided in English. If the worker
speaks neither English nor French, specify
the worker’s spoken language. The WSIB has
the ability to communicate with workers in
many languages.
A8
Y / D I S E A S E
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TABLE OF CONTENTS
Section B – Employer Information
B1 Trade and Legal Name
(if different from above)
Give the name of the employer. The Trade
Name is the commonly used name; the Legal
Name is what appears on legal documents.
If they are diff erent, provide both. This helps
to establish and administer the claim, avoid
delays and minimize postal errors.
Example:
The company Trade Name is “Sam’s Pizza”
and the Legal Name is “123456 Ontario Inc.”
So, give both names.

B2 Mailing Address, City/Town, Province,
Postal Code, Telephone, FAX Number
Give the full mailing address, including
postal code, of the employer. The WSIB will
send all correspondence for this claim to
this address.
B3 Check one:
Firm Number OR
Account Number Provide Number________
Check (√) either Firm Number or Account
Number and give the number in the space
provided.
This number is used to assign the claim to
the correct employer. The WSIB can establish
a claim using either number, but the Firm
Number is preferred.
B1
B2
B3
Firm Number
A six to eight digit number (may have
numbers and letters) used to identify and
track accident costs for both Schedule 1 and
Schedule 2 employers and to bill Schedule 2
employers.

For Schedule 1 employers, this number
appears on the top right corner of your
Premium Remittance Statement.
For Schedule 2 employers, this number
appears on the top left corner of your
Monthly Statement.
Account Number
A seven-digit number (numbers only) used
to identify and bill Schedule 1 employers.
This number appears on the top right
corner of your Premium Remittance
statement.
Many employers have several account and/or
fi rm numbers, depending on the type of
business they conduct. Providing the correct
number that is associated with this worker
will ensure that the claim is charged to the
correct employer, minimizing problems in
the future.
Y / D I S E A S E
G E 1 0
TABLE OF CONTENTS
Section B – Employer Information continued…

Rate Group Number &
Classifi cation Unit Code
The WSIB divides employer operations
into nine industry classes. These classes are
divided into Rate Groups. The Rate Groups
are further divided into Classifi cation Units
(CUs).
B4 Rate Group Number
WSIB sets premium rates by rate group.
Diff erent types of employment have diff erent
rate group numbers, even within the same
employer. The rate group number consists
of a three-digit rate number and a rate group
description.
Example:
Rate Group Number Description
030 Logging
If you have been assigned more than one
rate group number, please give the rate
group number that represents the type of
employment that the worker was doing at
the time of the accident/illness.
B5 Classifi cation Unit Code
In addition to the WSIB rate number, you
must also provide the classifi cation unit
(CU) code that identifi es a business activity,
or cluster of business activities within a rate
group. The WSIB records premiums and

accident costs by CU. Each Classifi cation
Unit Code has its own description and a
seven-digit number.
Example:
CU Code Description
0411-099 Logging Operations
If you have been assigned more than
one CU code, please record the CU code
that represents the business activity that
the worker was doing at the time of the
accident/illness.
The CU code can be found on your
Premium Remittance statement.
If the worker was engaged in an ancillary
(supportive) activity – for example, general
administration – and you cannot assign the
work performed to a specifi c CU, please
assign the CU code that represents the
highest proportion of your annual assessable
payroll.
B4 B5
B6 B7
B8
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For more information about your Firm
Number, Account Number, Rate Groups and
Classifi cation Unit Codes, contact your Account
Manager or Customer Service Representative. If
you do not know who your contact is, call the
WSIB general number at (416) 344-1000 or toll
free 1-800-387-0750.
B6 Description of Business Activity
Please provide a brief yet specifi c description
of what your business does.
Examples:
Retail Shoe Store
Bicycle Repair Shop
Automotive Manufacturing
For Schedule 1 employers, this description
appears on the top right corner of your
Premium Remittance Statement.
B7 Does your fi rm have 20 or more
workers?
yes no

At the time of the worker’s accident/illness,
please indicate if your fi rm employed 20
or more workers. This helps the WSIB to
properly deliver the right service to the
employer.
B8 Branch Address where worker is based
(if different than mailing address – no
abbreviations)
City/Town, Province, Postal Code,
Alternate Telephone
Ensure that you provide the address of the
location, branch, plant or department where
this worker reports to, if it is diff erent from
the mailing address. This information helps
us assign the claim to the correct WSIB offi ce
and service delivery team. Claim related
mail will not go here; it goes to the “Mailing
Address”.
The Alternate Telephone allows you to
provide us with the phone number at the
Branch Address location.
Example:
The company’s head offi ce may be in
Ottawa, but the branch offi ce/location
where this worker reports is in Kingston.
So, give the Kingston offi ce address here.
For construction, give the nearest
construction branch offi ce to which

the worker reports, and not the actual
worksite location.
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Section C – Accident/Illness Dates and Details
The information in this section provides us with the important
details surrounding the accident/illness.
The WSIB uses these details to help make the initial entitlement
decision on a claim. This information is
also used by us to develop prevention strategies that will reduce
workplace injuries/illnesses.
C1 1. Date and hour of accident/Awareness
of illness
Give the date and time that the accident/
illness occurred. This may be either:
a specifi c date/time such as in the case of
an incident like a trip and fall; or
the date/time when the worker states he/
she fi rst started to notice a problem.
Date and hour reported to employer
Give the date and time that the worker fi rst

reported the accident/illness to an employer
representative. An employer representative
may include:
fi rst aid attendant or offi cer,
immediate supervisor or site offi cial,
time offi ce or dispatcher, or
other employer offi cial.
C2 2. Who was the accident/illness
reported to?
(Name & Position) Telephone
Give the name of the individual to whom
the worker fi rst reported the accident/illness.
Remember to include this individual’s
position with the company as well as the
telephone contact number (including
extension) – if diff erent than the number
provided under Section B - Employer
Information.
C3 Was the accident/illness:
Sudden Specifi c Event/Occurrence
Gradually Occurring Over Time
Occupational Disease
Fatality

Indicate how the accident/illness occurred.
Sudden Specifi c Event/Occurrence
A chance event is an identifi able and
unintended event. You can see what
C1
C2
C3 C4
C5
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causes the injury (e.g. falling objects, slips,
trips, cuts). The injury is an expected
result of something identifi able and
unintended (e.g. a box falling from a shelf
hitting and breaking worker’s arm).
An unexpected result of working duties
from particular movements (e.g. lifts,
pulls, reaches, etc…) that causes sudden
and noticeable pain. (e.g. a warehouse
picker pulling a stuck box from a shelf
causing pain in the worker’s shoulder).

A willful and intentional act, with the
deliberate act not by the worker, but by
someone else, that results in an injury
(e.g. fi ghts between co-workers, police
offi cer assaulted by an individual, sales
clerk assaulted by a thief during a robbery,
etc…).
Gradually Occurring Over Time
This is an onset of an injury/condition
that has emerged over a period of time
(hours, days or longer), and where the
worker is unable to recall an exact point
when the injury/condition or pain started.
There is no identifi able event. The
worker may have started to notice pain
or discomfort while performing their
normal duties. (e.g. full-time cashier
continually scanning products with the
left arm and begins to experience pain in
the left elbow)
Occupational Disease
Choose this option only if it is clear that
there is an occupational disease as outlined
below:
An accident/illness in which a disease:
results from an exposure (sudden or over
time) to a substance in the workplace,

is peculiar to or characteristic of a
particular industrial process, trade or
occupation,
in the opinion of the WSIB, requires the
worker to be removed from the workplace
(temporarily or permanently) as exposure
to a substance may be a precursor to an
occupational disease, or
is mentioned in Schedule 3 or 4 of the
Workplace Safety and Insurance Act.
Fatality
An accident/illness that results in the death
of a worker.
C4 Type of accident/illness:
Check (√) the type (or category) of accident/
illness. If the type of accident is not on the
list provided, please check ‘Other’ and give a
description. The WSIB uses this information
to help create and deliver prevention
programs.
C5 Area of Injury (Body Part):
Check (√) all the areas of injury. Some areas
may not be listed here. If not listed, check (√)
‘Other’ and give a description in the space

provided. Remember to include ‘Left’ or
‘Right’ if applicable.
The areas provided are general physical
locations of the body. This information is
also requested on the Health Professional’s
Initial Report (Form 8) and the Worker’s
Report of Injury/Disease (Form 6) and will
be used by the adjudicator in the decision-
making process.
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C6 Describe what happened to cause the
accident/illness and what the worker
was doing at the time…
Give a written account outlining the
details of the cause of the accident/illness
as reported and reviewed through your
accident investigation process. This is the
“story” of what happened. Give as much
detail as possible. If needed, use a separate
sheet to provide details and include it as an
attachment to this Form 7. Please note that
any attachment to the Form 7 is considered
to be part of the Form 7 and a copy is to be
given to the worker.

Examples:
The worker slipped, fell or tripped…
The worker was struck by… or bumped
into…
The worker twisted her left ankle or left
knee…
If you are not aware of a specifi c accident/
incident that caused the injury/illness,
describe what the worker was doing and the
eff ort involved when the onset of pain, or
when the disease, was fi rst noticed.
Examples:
The worker was in an awkward position…
The worker was doing strenuous work…
The work was repetitive…
The worker was not accustomed to…
Include any details about the work area,
materials or equipment used, other people
involved or any detail that you believe is
important.
If your fi rm has a physical demands analysis
(PDA) of the work the worker was doing
at the time of the onset, please attach a
copy to this Form 7. If you would like to

obtain a PDA form, along with examples
on how to complete it, please visit our
website – www.wsib.on.ca under “Employer
Forms” and download “Physical Demands
Information Form (Form #2830A)”.
C6
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C7 Did the accident/illness happen on
the employer’s premises (owned, leased
or maintained)?
yes no Specify where (shop fl oor,
warehouse, client/customer site, parking lot, etc…)
Check (√) here if the accident/illness
occurred, or did not occur, on property
that is owned, leased or maintained by the
employer.
If yes, please indicate where on your premises
it did occur.
If no, give the actual location of where it

happened. The adjudicator may contact you
for more details.
Example:
<√> yes – assembly line, shop fl oor,
warehouse storage area, parking lot.
<√> no – delivery driver making a delivery to
a restaurant slips on the greasy kitchen fl oor;
provide the name of the restaurant.
C7
C8
C8 Did the accident/illness happen outside
the Province of Ontario?
yes no – If yes, where (city, province/
state, country).
Check ‘yes’ if the accident/illness occurred
outside of Ontario. If yes, the worker may
have the choice of claiming benefi ts either in
Ontario or where it happened.
If claiming in Ontario, the worker must sign
an election form. This question prompts the
WSIB to send an election form to the worker
at the time of claim registration, avoiding
potential delays. Although a claim can be
established, a decision cannot be made until
the election form has been received and

approved by the WSIB. The worker has three
months from the day of accident to submit
the election form.
Example:
An Ontario truck driver has a motor vehicle
incident in Alberta. The worker has the
choice to claim in Alberta or Ontario, and
uses the election form to indicate that choice.
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C9 Are you aware of any witnesses or other
employees involved in this accident/
illness?
yes no – If yes, provide name(s),
position(s) and work phone number(s).
Check ‘yes’ if:
anyone saw what happened,
other employees were involved in the
worker’s accident/illness, or
anyone has knowledge of the accident/

illness.
If yes, give the name(s), position(s) and work
phone number(s) in the space provided.
For injuries that occurred gradually over
time, it may be helpful to provide the name
of employees who may be aware of the
worker’s condition.
As part of the claim decision-making process,
the WSIB may need to speak with them.
C10 Was any individual, who does not work
for your fi rm, partially or totally
responsible for this accident/illness?
yes no – If yes, please give name and
work phone number.
Check ‘yes’ if any individual(s), not employed
by your fi rm, had any part in this worker’s
accident/illness. If yes, write the name(s)
and work phone number(s) in the space
provided.
As part of the decision-making process,
the WSIB may need to speak with them.
The WSIB will investigate and review if we
should transfer the costs associated with this
claim, either in whole or in part, from your
fi rm to the other responsible party.
Example:
John is making a delivery of produce at Joe’s

Fast Food Restaurant. John slips, injuring his
right ankle, due to grease on the restaurant
kitchen fl oor. Joe’s Fast Food Restaurant
may be responsible for all or part of the
costs associated with John’s claim. (This only
applies to Schedule 1 employers.)
C9
C10
C11
C12
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C11 Are you aware of any prior similar or
related problem, injury or condition?
yes no – If yes, please explain.
Check ‘yes’ if you are aware if this worker
has had any prior similar problems, injuries
or conditions that may be related or
contributing to the worker’s current reported

injury/condition. In the space provided,
write a brief outline of what you believe
they are. The WSIB may investigate further
to determine if the prior problem, injury or
condition has any impact on the worker’s
present problems. If you need more space,
use a separate sheet and include it as an
attachment to this Form 7.
C12 If you have concerns about this claim,
attach a written submission to this form.
submission attached
The employer may have concerns regarding
the accident/illness. If so, please attach a
separate submission to this Form 7 and
check (√) here if you are doing so. Any
attachments to the Form 7 are considered to
be a part of the Form 7, and copies are to be
given to the worker.
Please include the worker’s name and social
insurance number or the claim number (if
available) on all pages being attached.
This is your opportunity to provide any
further information not already requested in
the form.
Provide supporting information if you
have reason to doubt this claim. The WSIB
will investigate further before making a
decision. If you do not provide supporting
information about why you doubt the claim,
a decision will be made with the existing

information on the fi le.
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Section D – Health Care
The worker has the right to make the initial choice of health
professional. A health professional includes
chiropractor, physician, physiotherapist, registered nurse
(extended class) or dentist. For further information
see the WSIB Operational Policy 17-01-03 – Choice and Change
of Health Professional.
At the time an accident/illness occurs, the employer is
responsible for the initial transportation of the
worker (if needed) to a facility for health care or treatment. The
employer is also responsible for paying the
cost of transportation (e.g. ambulance, taxi, etc).
D1 D2
D3
D1 Did the worker receive health care for
this injury?
yes no – If yes, when:
Check ‘yes’ if this worker was provided with

any health care as a result of the accident/
illness.
If yes, please indicate when the health care
took place. This also includes any health care
given to this worker at the worksite. Do not
confuse this with fi rst aid.
First aid refers to any care provided to a First aid refers to any
care provided to a First aid
worker that could be given by a trained
fi rst-aider (e.g. washing a wound, applying
a dressing, etc…) even if done by an in-
house health professional. If the injury only
requires fi rst aid, a Form 7 does not have
to be completed and sent to the WSIB.
However, under the Occupational Health and
Safety Act, the employer is required to keep a
record of any fi rst aid administered.
Health care refers to professional services
provided by any of the following registered
health care professionals: chiropractor,
physician, physiotherapist, registered nurse
(extended class) or dentist. Health care can
be received from a hospital, other facility
(emergency department, walk-in clinic,
health professional offi ce, etc…) or the
worksite. A Form 7 must be completed and
submitted if the worker got health care.
The employer should make every reasonable
eff ort possible to obtain this information. If
this information is not possible to obtain,
please provide an explanation of what is

being done to get it.
D2 When did the employer learn that the
worker received health care?
Give the date when the employer was fi rst
advised, or made aware, that the worker got
health care for the reported accident/illness.
The reporting obligation for the employer
begins once they learn that the worker got
health care for the work related accident/
illness.
D4
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D3 Where was the worker treated for this
injury?
If known, check (√) the place(s) where the
worker received health care for his/her
injury/illness. (Defi nitions provided below).
Please check (√) all that may apply.

On-site health care
This refers to any health care provided at the
workplace or worksite, where the accident/
illness happened.
Ambulance
If an ambulance was called. This could
indicate how serious the accident/illness
is and will trigger special attention by the
WSIB. If an ambulance is called on the
day of accident/illness, the employer is
responsible for paying the cost.
Emergency department
This may be provided within a hospital or
a specialized emergency facility outside of a
hospital. Please give the name and location
of the hospital or emergency facility.
Admitted to hospital
The worker may have been admitted to a
hospital for an overnight stay. This could
indicate how serious the accident/illness
is and will trigger special attention by the
WSIB. Please give the name and location of
the hospital.
Health professional offi ce
Many health professionals have their own
private practice and this refers to that health
professional’s independent offi ce.

Clinic
This refers to a walk-in clinic or a facility
where several health professionals provide
health care. The clinic may be a multi-
disciplinary clinic with several diff erent types
of health professionals.
Other
If the worker sought health care from anyone
not listed above, please indicate it here (e.g.
Nursing Station).
D4 Name, address and phone number of
health professional or facility who
treated this worker (if known)
In the space provided, print the name and
contact details of who provided the worker
with this health care.
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Section E – Lost Time – No Lost Time
The employer is responsible for paying the worker’s full wages
for the day of the accident/illness. Following

that day, any lost time or reduction in wages that results from
the accident/illness must be reported to the
WSIB. The worker may be entitled to receive WSIB loss of
earnings benefi ts.
E1
E2
E1 1. Please choose one of the following
indicators.
You must choose one and only one of the
options and complete the remainder of the
form as indicated.
After the day of accident/awareness of
illness, this worker:
Returned to his/her regular job and has not
lost any time and/or earnings. (Complete sections
G and J).
In this situation, the worker has returned
and continued to do his/her regular
job/work duties without requiring any
changes or accommodations to the work
or the workplace after the day of accident/
illness.
The worker has not lost any time from
work beyond the day of accident/illness
and there has been no reduction or
change in wages or earnings.
Returned to modifi ed work and has not lost any

time and/or earnings. (Complete sections F, G and
J).
In this situation, the worker has returned
to work after the day of accident/illness.
Changes or accommodations were
required to the work or the workplace in
order for the return to work to occur.
The worker may be continuing with
modifi ed work or, following a period of
modifi ed work, is now back to his/her
regular job/work duties.
The worker has not lost any time from
work beyond the day of accident/illness
and there has been no reduction or
change in wages or earnings.
This situation also includes any
temporary changes, alterations or
modifi cations to the worker’s shifts or
schedule.
Example:
A warehouse worker sustains a shoulder
injury and returns to work with no above
shoulder level work for one week.
A delivery driver returns to work with no
driving for two days, and then resumes
regular driving duties.

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Has lost time and/or earnings. (Complete ALL
remaining sections).
Please check (√) this box if any of the
following apply:
1. The worker is absent from work beyond
the day of accident/illness. This absence
may be for part of a day, an entire day
or more. This includes an absence for
a medical appointment or health care
treatment for the injury. The worker may
have returned to work after the absence.
2. The worker has experienced a reduction
in earnings. This reduction may be the
result of working at a lower paying job,
losing a shift premium or production
bonus, or other similar circumstances.
3. The worker is losing time from work, but
the employer continues to pay the worker.
4. The worker returned to work, but was
unable to continue.
Provide the date that the worker fi rst lost

time and/or earnings. If you, as the employer,
are not sure if this worker will lose time or
earnings, you should make every reasonable
eff ort to obtain this information. If you are
unable to obtain this information, please
provide an explanation of what is being done
to get it.
If the worker returned to work, before the
submission of the Form 7, give the return to
work date. Indicate if the return to work was
to regular work or modifi ed work.
E2 2. This Lost Time – No Lost Time –
Modifi ed Work information was
confi rmed by:
Myself Other Telephone
Name:___________________
In many situations, the individual
completing the Form 7 may not have
direct or fi rst hand knowledge of the
accident/illness details, lost-time/no lost
time, or return to work information. Give
the name of the individual who supplied
this information as the WSIB may need to
contact them for further clarifi cation.
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Section F – Return to Work
A worker may have work or task limitations as a result of the
work related accident/illness. To assist you in
helping the worker get back to work safely, you will need to be
aware of those work/task limitations. You
can use this information to set up modifi ed work that
accommodates the worker’s limitations.
To obtain work/task limitations, you can give a copy of the
WSIB’s “Functional Abilities Form for Timely
Return to Work” Form #2647 (FAF) to the worker. Have the
worker get it completed by their health
professional and a copy returned to you.
Getting the FAF
Fax your request to the WSIB at 1-888-313-7373. Include the
employer name, address and the number of
forms required. Print clearly to avoid postal errors.
Other ways to get work/task limitations are:
By using your own return to work form; or
Through a medical/clinical note or report from the health
professional.
Please note: The WSIB will only pay for completion of the
WSIB “Functional Abilities Form for Timely
Return to Work” (FAF). Payments for any other employer
supplied forms are the responsibility of the
employer.

F1 F2 F3
F4
F1 Have you been provided with work
limitations for this worker’s injury?
yes no
Following the receipt of health care, the
worker may require work/task limitations
due to the injury/illness. Please check if you
have been provided with any limitations for
the worker.
If you have work/task limitations, please
attach them to the Form 7.
If no work/task limitations are available,
discuss with the worker how to get them
and any other concerns the worker may have
about return to work.
For further assistance on return to work, you
can contact:
your account manager/customer service
representative, or
your adjudicator.
F2 Has modifi ed work been discussed with
this worker?
yes no

Check ‘yes’ here if there has been a discussion
about a return to work with the worker.
This discussion can include any work/task
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limitations, job duties, accommodations or
other options to facilitate return to work.
Based on the discussion, it should become
clear if a return to work is possible.
If no discussion about return to work has
taken place, you should arrange with the
worker to do so. You should also review
what work you may have available and what
changes you can make to the worker’s duties
to accommodate a return to work.
F3 Has modifi ed work been offered to this
worker?
yes no
Check ‘yes’ if there has been an off er of
modifi ed work given to the worker. This
off er should be specifi c with all details
clearly understood by everyone.

If yes, was it
Accepted
Declined
If Declined please attach a copy of the written
offer given to the worker.
Check (√) to indicate the outcome of the
return to work.
If declined by the worker, provide the worker
and the WSIB with a written copy of the
return to work off er.
Providing a written copy is not an obligation,
but is a recommended best practice. A
written off er establishes and documents
what the employer off ered. You should be
able to demonstrate that the worker received
a copy of the written off er. Provide the WSIB
a copy as this gives the adjudicator a clear
idea of the modifi ed work off ered and assists
in further decision-making.
If you encounter diffi culties in the return to
work process, please contact your adjudicator.
F4 Who is responsible for arranging the
worker’s return to work?
Myself Other Telephone
Name:___________________
In many situations, the person completing

the Form 7 may not be the person directly
responsible for arranging the worker’s
return to work. Should problems or issues
arise during the return to work process,
the adjudicator must be able to contact the
person responsible for arranging the return
to work. Otherwise, the return to work
process and decisions surrounding return to
work can be delayed.
Please give the name of the person
responsible for setting up the return to work
and the phone number if diff erent from the
phone number provided under Section B -
Employer Information.
If the person responsible for setting up the
return to work is an external consultant
or representative, provide the written
authorization of representation for them to
act on the employer’s behalf.
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Section G – Base Wage/Employment Information
This information is requested in all claims. The worker’s
employment type and basic rate of pay should be
readily available. For no lost time claims, we do not expect the

employer to make elaborate calculations (e.g.
commission sales, piecework) regarding rate of pay. In lost time
claims, we expect the complete rate of pay
information.
When a claim changes from no lost time to lost time, obtaining
the worker’s complete earnings
information may take time. This change of claim status may
occur several weeks, months or years after the
claim is originally allowed. The adjudicator must be able to
issue payment in these claims. The worker’s
employment type and basic rate of pay can be used to pay benefi
ts on a temporary basis until the employer
has provided the complete earnings information to the WSIB.
G1
G1 Is this worker
Indicate the worker’s employment status by
checking the appropriate box(es). A worker
may have more than one status.
You may be aware that your employee also
works for another employer. If this is the
case, also check the “Other” box and explain.
Examples:
The worker may be a:
(√) Permanent Full Time worker, or
(√) Temporary Full Time worker on a (√)

Contract, or
(√) Permanent Full Time worker who is a
(√) Registered Apprentice
Defi nitions
Permanent (Full-Time or Part-Time)
This, also known as Regular, is when a
worker:
has been hired by the employer to work
52 weeks a year with no seasonal or
cyclical layoff s,
has no set termination date,
has a set number of hours worked per
week.
Examples:
Permanent Full-Time – Bob has worked
continuously for over 10 years for the ACME
Company, Monday to Friday, 40 hours per
week.
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Permanent Part-Time – Jane has been a cashier
with The A & B Supermarket Ltd. for the
past 7 years, normally scheduled to work 15
hours per week.
Please note: A worker in Permanent
employment, whose earnings vary from
day to day or week to week due to irregular
hours or method of payment, is also
considered to be in “Irregular” employment.
Temporary (Full-Time or Part-Time)
This is a worker who has a set number of
hours worked per week and:
is hired for a specifi c period of time, or
has a termination notice (e.g. contract
workers), or
is hired for a temporary period through a
union hall, or
there is no guarantee of ongoing
employment.
Temporary workers may include temporary
agency workers (workers who work for
an agency that hires them out to other
employers).
Examples:

Temporary Full-Time – Judy is hired as a full-
time executive assistant for a one year period
to cover for an employee off on maternity
leave.
Temporary Part-Time – Jasper has been hired
to work as a security guard for 4 hours per
day for a one-time special event (3-day music
festival).
Casual/Irregular
This is when a worker has no set schedule or
hours of work. This would also include “On-
Call” workers.
Example:
Sara works as a waitress for Black’s Bar. There
is no set schedule for her work and she only
knows from week to week her upcoming
hours and shifts. There is no minimum
guarantee of hours.
Seasonal
Seasonal, or cyclical workers, are employees
hired to work for certain times of the year
and with periods of layoff expected.
Example:
Martin is hired to work at a large amusement
park for the summer season only.
Contract

This is when a worker is hired to work at
a specifi c job at a specifi c rate of pay and
usually for a specifi c period of time.
Example:
Terry has been hired on a three-month
contract to work as a data entry operator
for 24 hours a week to clear-up a backlog of
invoices.
Student
A student is defi ned as:
a community college student
a high school student
a night school student
a university student
Secondary school students who are registered
in Ministry of Education work education
programs and who are placed with an
employer (placement host) to gain practical
work experience, and who are not paid by
the placement host, have WSIB coverage
during the placement. The Ministry of
Education provides coverage. These students,

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TABLE OF CONTENTS
also referred to as pupils, are deemed to be
workers under the Education Act.
Examples:
Simone is a college student working part-
time after school at a local restaurant.
Adrian is a high school student in a co-op
program at the local museum.
(For more detailed information about
students, please refer to WSIB Operational
Policy 12-04-07. The WSIB Operational
Policy Manual can be found on the WSIB
website at www.wsib.on.ca).
Unpaid/Trainee
Individuals who are placed by a training
agency (i.e. Goodwill, March of Dimes)
with a host employer to obtain skills
and experience, but are not paid by that
employer, are called Unpaid Trainees and/or
Learners. Although not under a contract of
service or apprenticeship, they are considered
workers and are entitled to benefi ts if
injured.

If an accident/illness does occur, the host
employer is responsible to report this to
the WSIB. When reporting, use the entry
level pay for the job being done. The host
employer would not be responsible for the
costs associated with the claim.
Example:
Anthony, who has a learning disability, has
been placed by the Ontario Works Program
with a local repair shop to gain experience in
small engine repair.
Registered Apprentice
An apprentice is a person registered under
the Trades Qualifi cation and Apprenticeship
Act (specifi ed construction trades) or the Act (specifi ed
construction trades) or the Act
Apprenticeship and Certifi cation Act (all Apprenticeship and
Certifi cation Act (all Apprenticeship and Certifi cation Act
other trades), who has signed a contract of
apprenticeship for training and instruction
in a trade, through or from an employer.
Please provide the “Registered Apprentice
Number” in the space provided beside
“Other”
Example:
Frank is employed by ABC Masonry Ltd. as
an apprentice stone mason.

Optional Insurance
Check (√) this box to indicate if the person
who is injured has optional insurance
coverage. For more information on Optional
Insurance, please refer to Fact Sheet #0121A
– “Optional Insurance”, available on our
website www.wsib.on.ca in the Reference
tab, under “General”.
Optional insurance may be applied for by:
owner/operators (as previously defi ned),
executive offi cials, and
elected offi cials.
Example:
Meileen is a physician in her own practice
and has applied for optional insurance
coverage.
Owner Operator / (Sub) Contractor
Check this box if the following situation
applies to you:
1. The following are considered to be an
owner/operator of a business:
independent operator, or
sole proprietor, or

a partner in a partnership.
These people may apply to purchase optional
insurance coverage under the Workplace
Safety and Insurance Act.
Section G – Base Wage/Employment Information continued…
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TABLE OF CONTENTS
OR
2. Individuals who are contracted or
commissioned to do work and perform
the work personally. If either party
considered the work arrangements to
be a business relationship of purchaser/
independent operator, both are strongly
encouraged to obtain a ruling on the
relationship.
The WSIB reserves the authority to
determine, on a case by case basis, whether
the individual is a worker, or in fact,
an owner operator, (sub) contractor or
independent operator.
If you need assistance with this call your

local Account Manager or Customer Service
Representative. The phone numbers for each
District offi ce is located on the back cover of
this guide.
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G2
Section G – Base Wage/Employment Information continued…
G2 2. Regular rate of pay
Provide the worker’s normal/regular gross
rate of pay at the time of the accident/illness
here. This should not include any bonuses,
premiums, diff erentials, etc…
Examples:
$9.00 per hour
$100.00 per day
$450.00 per week
$35,000 per year

If the rate of pay is diffi cult to provide (e.g.
commission sales, piecework, etc.), we do not
expect the employer, if there is no lost time
or pay after the day of accident/illness, to
make any calculations. Rather, describe the
type of pay in the “Other” space and include
any base pay, if applicable.
Example:
Other – $7.15 per hour + 5% Commission on
sales.
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Section H – Additional Wage Information
If a worker has lost pay as a result of a work related accident,
he/she may be entitled to a loss of earnings
(LOE) benefi t. The WSIB needs complete and accurate
earnings information to calculate loss of earnings
for workers.
In certain cases, the benefi t rate is recalculated at the 13th
week to ensure that the worker’s long term
earnings are more fairly refl ected (e.g. profi t sharing, yearly
bonuses, vacation accrual). For further
information regarding Short-Term and Long-Term Earnings, see
Fact Sheet #0794A – “Determining Average

Earnings”, available on our website www.wsib.on.ca in the
Reference tab, under “General”.
This section has been designed to enable most employers to give
wage information. We do appreciate that
there are unique situations that cannot be accommodated here.
For those employers, we recommend that
you contact the adjudicator directly to give the required wage
information.
H1 1. Net Claim Code or Amount
Federal Provincial
The WSIB needs the Federal and Provincial
“Net Claim for Exemption” or “Net Claim
Code” to calculate the worker’s benefi t rate.
Provide the amount or the code in each of
the spaces provided.
H2 2. Vacation pay – on each cheque?
yes no Provide percentage _____ %
Check (√) whether vacation pay is given
on each pay cheque and provide the actual
percentage.
Vacation pay issued on each cheque will be
included in calculating the worker’s benefi t
rate.
The information requested in questions 3 to
6 is used to determine when payment of loss
of earnings to the worker is to start.

H3 3. Date and hour last worked
dd/mm/yy AM
PM
H4 4. Normal working hours on last day
worked
From AM To AM
PM PM
H5 5. Actual earnings for last day worked
$ __________________________
H6 6. Normal earnings for last day worked
$ __________________________
Please Note: The employer is responsible
for full wages on the day of accident. WSIB
benefi t payments may begin after that day.
H1 H2
H3 H4 H5 H6
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TABLE OF CONTENTS

Section H – Additional Wage Information continued…
H7 7. Advances on wages
Is the worker being paid while he/she recovers?
yes no
If yes, indicate: Full/Regular Other
Check (√) whether you are continuing to pay
the worker all or part of his/her salary when
the worker may be entitled to WSIB benefi ts.
Indicate “Full/Regular” when you continue
the worker’s full salary, or “Other” when you:
continue a percentage of the worker’s
regular salary, or
give a loan or lump sum advance, or
have any other arrangement.
In cases where advances are being extended
by the employer, we will redirect benefi t
entitlement to that employer at the rate we
would normally pay the worker, if lost time
is allowed.
H8 8. Other Earnings (Not Regular Wages)
Provide the total of additional earnings for each
week for the 4 weeks before the accident/illness.
A worker may have additional earnings on

top of his or her regular rate of pay (provided
in section G – Question 2). These additional
earnings could be:
overtime pay (mandatory and/or
voluntary)
premiums
commissions
bonuses
diff erentials
tips & gratuities
room & board
in-lieu of payments, etc…
For a complete list of allowable earnings,
see WSIB Policy #18-02-02, available on our
website www.wsib.on.ca in the Policy tab
under “Operational Policy Manual”.
We may include these additional earnings,
along with the regular rate of pay, when
calculating a worker’s benefi t rate.
The “Other Earnings” chart is to help the
employer provide us with any additional
earnings information based on the four
weeks prior to the accident/illness. Provide
us the “From Date” and “To Date” for each
week.

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