Follow the steps to successfully fill out the form.

1. Press the ‘Get Form’ button to access the form and open it in your chosen editor.
2. Begin by entering the WCB claim number at the top of the form. This is crucial for tracking your incident report.
3. In the 'Worker & Plan Details' section, provide the worker's surname followed by their first name and initial.
4. Fill in the address, including city or town, province, and postal code to ensure accurate identification.
5. Input the worker's date of birth in the format yyyy/mm/dd, followed by the date of the accident in the same format.
6. Enter the claim owner's name and their telephone number. This ensures that all relevant parties can be contacted as needed.
7. Provide the provider's name and telephone number in the designated fields for clarity regarding service delivery.
8. Record the date and time the report is faxed to the WCB, ensuring you are within the required 24-hour timeline.
9. Fill in the provider reference number for organizational purposes.
10. In the 'Description of Incident' section, provide a detailed account of the incident, including relevant dates and times.
11. Indicate whether there have been similar incidents in the past by circling 'Yes' or 'No.' If 'Yes,' detail previous attempts at resolution and their outcomes.
12. Make sure to offer recommendations on how to resolve the current incident in the designated section.
13. Specify to whom a copy of the report is provided: the worker, WCB, or provider.
14. Print the submitter’s name and telephone number accurately to ensure proper follow-up.
15. Finally, sign the form in the 'Signature of Submitter' section to validate the report before submission.
16. After completing the form, save your changes, and proceed to download, print, or share the form as necessary.

Complete your documents online today to ensure a timely and effective response to your incident report.