Get Wsib Optional Insurance Request Change Form

Filling out the Wsib Optional Insurance Request Change Form online can be a straightforward process if you follow the appropriate steps. This guide provides a professional and supportive approach to help you accurately complete the form based on your specific needs.

Follow the steps to complete your form successfully.

1. Press the ‘Get Form’ button to access the Wsib Optional Insurance Request Change Form and open it in your editor.
2. In the first section, provide your Account Number and Firm Number as required. Ensure to include a valid Telephone Enquiry Number.
3. If you are requesting optional insurance or changing your existing coverage amount, complete sections A and B for new requests or section C for changes. Additionally, provide proof of earnings and ensure the applicant reviews and signs the Optional Insurance Declaration.
4. In section A, fill in your First Name, Last Name, Middle Name, Date of Birth, and Title/Position with the company. Also, provide your physical Home Address, including City, Province, Postal Code, and Telephone Number.
5. For new requests in section B, specify the Amount of Coverage Requested and Today's Date, ensuring that the applicant’s signature is included.
6. If requesting a change, complete section C by entering the Revised Coverage Amount Requested and Today's Date, along with the applicant's signature.
7. If canceling existing optional insurance, make sure to complete section D by providing your name, today's date, and the required signatures.
8. Review the Optional Insurance Declaration carefully and ensure that the applicant signs and dates it accordingly.
9. Complete the Owner's Certification by having the Owner or Authorized Officer provide their name, title, signature, and telephone number, along with the date completed.
10. Once all sections are complete, save your changes, and you can choose to download, print, or share the form as needed.

Complete your Wsib Optional Insurance Request Change Form online today for a smoother process.