Get Workers Compensation Request Form

Section E Bankruptcy Date of Insolvency Contact Person s Name Name of Receiver or Trustee Contact Phone Number A 635 REV FEB 2014 Page 2 of 2 Section F - Sale of Business Type of Sale Amalgamation Share Acquisition Date of Sale Sale of all assets Partial sale of assets What type of relationship exists between the purchaser and seller Other Is there any common ownership between the Business Personal Please list what assets have been sold Solicitor s Name Solicitor s Phone Number Purchaser s Company Name Purchaser Address Purchaser Phone Number Will there be continuous ownership Purchaser Fax Number Will workers and equipment be continued Section G Applicant Authorization By my signature I certify that I have the authority to execute this request and the facts set forth on this application are true and correct to the best of my knowledge and belief. I am aware that any person operating in a compulsory industry who does not secure or maintain Workers Compensation coverage and comply with the Alberta Workers Compensation Act or knowingly provides false or misleading information to the Board may be subject to administrative penalties or guilty of an offence under that Act. Name Position Home Phone Number Contact Number Email Address WCB mailing address PO Box 2415 Edmonton AB T5J 2S5 Signature In Calgary In Edmonton Fax 403 517-6201 Phone 403 517-6000 Fax 780 498-7999 Phone 780 498-3999 Date Toll Free in Alberta Outside of Alberta 1-866-922-9221 1-800-661-9608 Online www. wcb. ab. ca The personal information collected on this form will be used for the purpose of closing your WCB-Alberta account. A635 Closing Account Request To avoid delays in the processing of your application please complete all fields in detail* Section A - Company Information Account Number Legal Business Name Operating or Trade Name if applicable Street Fax Number Final Mailing Address Business Phone Number City/Town Province Postal Code Section B - Personal Coverage Information Owner s/Director s Legal Name P. C I. D. Is personal coverage to be terminated Is coverage split in another company Yes No If yes list the account number s. Section C - Employee Information Employers have 10 business days to notify WCB of closing worker information* Industry 1 Last date worker s employed Actual gross earnings from Jan* 1 to close date. Include all full-time part-time casual or temporary workers as well as all subcontractors who the WCB considers to be your workers for the current calendar year. Section D - Business Closing Please indicate why the account is to be closed Bankruptcy/Insolvency See Section E Seasonal Cease of Operations/ no more workers Sale of Business see Section F Voluntary Operations Withdrawal Should coverage automatically resume upon rehire Other explain Please list companies for whom you have most recently performed work. Section E Bankruptcy Date of Insolvency Contact Person s Name Name of Receiver or Trustee Contact Phone Number A 635 REV FEB 2014 Page 2 of 2 Section F - Sale of Business Type of Sale Amalgamation Share Acquisition Date of Sale Sale of all assets Partial sale of assets What type of relationship exists between the purchaser and seller Other Is there any common ownership between the Business Personal Please list what assets have been sold Solicitor s Name Solicitor s Phone Number Purchaser s Company Name Purchaser Address Purchaser Phone Number Will there be continuous ownership Purchaser Fax Number Will workers and equipment be continued Section G Applicant Authorization By my signature I certify that I have the authority to execute this request and the facts set forth on this application are true and correct to the best of my knowledge and belief* I am aware that any person operating in a compulsory industry who does not secure or maintain Workers Compensation coverage and comply with the Alberta Workers Compensation Act or knowingly provides false or misleading information to the Board may be subject to administrative penalties or guilty of an offence under that Act.