Direct Deposit Request
CONFIDENTIAL
Claim Number
Please PRINT in black ink.
*Must be Completed*
Claimant's Name & Address (please print clearly)
Instructions for completion of the form:
1) Select either method A, B, OR C below
2) If choosing method A or B, sign the bottom of this form. If choosing option C, sign the bottom of the bank form
3) When complete, return to WSIB by one of the following ways:
Email to: DirectDeposit@wsib.on.ca (This email to be used
for the sole purpose of submitting direct deposit forms only).
Mail to: The Workplace Safety and Insurance Board,
Treasury Branch 7th Floor, 200 Front Street West,
Toronto ON M5V 3J1
• •
Fax to: 416-344-4684 OR 1-888-313-7373
•
Select ONE of A, B OR C to complete (direct deposit is only available for financial institutions within Canada)
Example:
Provide a copy of a void cheque:
A
personalized cheque with name (must be preprinted by bank)
BANK COUNTER CHEQUES ARE NOT ACCEPTABLE
•
1
print "VOID"”across your cheque
•
2
attach the cheque to direct deposit form and return to WSIB
•
OR
For Financial Institution (F/I) Use
Bank Stamp:
B
Stamp
have your bank/financial institution complete and
stamp this section with your banking information
•
complete and sign and return to WSIB
•
Branch No. Bank I.D. Account No.
Telephone
F/I Rep Date
OR
Pre-authorized Direct Deposit Form
C
go to your bank to obtain a pre-authorized direct deposit form
•
ensure that your claim number, name, and signature are included on the pre-authorized bank direct deposit form
•
your bank may be able to fax the form to the WSIB on your behalf
•
Please sign below if choosing method A or B
My/Our signature(s) on this document authorizes the Workplace Safety and Insurance Board (WSIB) to credit the above
account. The direct deposits represent benefits payable only to the individual named above. Any changes in circumstances
(i.e. death, mailing address) must be reported to the WSIB.
Signature of Bank Account Owner Date Telephone
X
Name (please print) and Signature of Co-Owner of Bank Account (if applicable) Date Telephone
X
3072A (06/16)
DDS2
Type your name and upload, or print and sign before returning to WSIB.
