Get Workers Compensation Request Form

Completing the Workers Compensation Request Form online can be a straightforward process when guided properly. This guide provides step-by-step instructions to help you accurately fill out the necessary information required for processing your request.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out Section A, which requires your company information. Provide your account number, legal business name, operating or trade name (if applicable), the street address, fax number, business phone number, city/town, province, and postal code.
3. Proceed to Section B to input personal coverage information. Here, enter the owner’s or director’s legal name and their personal coverage identification (P.C I.D.). Indicate whether personal coverage is to be terminated, whether coverage is split in another company, and if so, provide the relevant account numbers.
4. In Section C, provide employee information. Ensure you list the industry, the last date workers were employed, and the actual gross earnings from January 1 to the closure date for all relevant workers.
5. Fill out Section D, detailing the reason for account closure. Indicate if it's due to bankruptcy/insolvency, seasonal operations, a sale of the business, voluntary operations withdrawal, or other reasons. Also, specify if coverage should automatically resume upon rehire.
6. Section E requires information on any bankruptcy. Enter the date of insolvency, the contact person’s name, the name of the receiver or trustee, and their contact phone number.
7. In Section F, indicate the type of sale if applicable. Provide the date of sale, types of assets sold, and information regarding the relationship between the purchaser and seller, including any common ownership.
8. Complete Section G by authorizing the application. Sign with your name, position, home phone number, contact number, fax number, email address, and date.
9. Review all fields to ensure the information is correct. Once confirmed, you can save changes, download, print, or share the completed form as needed.

Start filling out your Workers Compensation Request Form online to ensure a smooth closing process.