Date (dd/mmm/yyyy) Is this a new address Yes No Home phone Initial Postal code B. Expense information Original receipts plus prescriptions must be attached. This form is not to be used for medication reimbursement. Description of Who recommended this for you Quantity service/product (name, address and phone number) Additional comments Date purchased/ of service Amount ($) Total C. Worker declaration I hereby certify, that to the best of my knowledge, the information provided.
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How to fill out the Canada WSIB Ontario 3164A online
Filling out the Canada WSIB Ontario 3164A form online can be a straightforward process when guided step by step. This guide provides you with a clear understanding of each section, ensuring that you complete the form accurately and effectively.
Follow the steps to complete your form successfully.
- Click ‘Get Form’ button to obtain the form and open it in your preferred editing interface.
- Begin completing Section A: Worker information. You will need to fill in your last name, first name, current address, city, province, work phone, and birth date in the format dd/mmm/yyyy. Additionally, indicate whether your address is new by selecting 'Yes' or 'No'. Don't forget to provide your home phone number and postal code.
- Proceed to Section B: Expense information. In this section, you must attach original receipts and prescriptions. Note that this form is not for medication reimbursement. List the description of the service or product, who recommended it to you, the quantity, and any additional comments. Include the date you purchased or received the service and the total amount spent in dollars.
- Move to Section C: Worker declaration. Here, certify that all provided information is true, accurate, and complete. You will also agree that the services listed were received and that you will provide all original receipts. Fill in your name, provide your signature, and enter the date in dd/mmm/yyyy format. If submitting electronically, check the box indicating that this represents your electronic signature.
- Finally, review the form for accuracy. Once verified, you can save the changes, download the form, print it, or share it, as required.
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