September 2017 Page 1 of 2
Student Declaration of Understanding
Workplace Safety and Insurance Board or Private Insurance Coverage for
Students on Unpaid Placements
Student coverage while on unpaid placement:
The government of Ontario, through the Ministry of Advanced Education & Skills Development
(MAESD), reimburses WSIB for the cost of benefits it pays to Student Trainees enrolled in an
approved program at a Training Agency (university). Students enrolled at an Ontario
postsecondary institution are eligible for Workplace Safety Insurance Board (WSIB) coverage
while on placements, either required or optional, that are part of an Approved Program. (
See the
Guidelines for details regarding eligibility for Ministry coverage.)
MAESD also provides private insurance through Chubb Insurance (formerly ACE-INA) to
students should their unpaid placement take place with an employer who is not covered under
the Workplace Safety and Insurance Act and limited coverage where eligible placements take
place outside of Ontario (international and other Canadian jurisdictions). However, students are
advised to maintain insurance for extended health care benefits through the applicable student
insurance plan or other insurance plan.
Please be advised that McMaster University will be required to disclose personal information
relating to the unpaid work placement and any WSIB claim or Chubb claim to MAESD.
This Agreement must be completed, and signed to indicate the Student Trainee’s acceptance of
the unpaid work placement conditions, and a copy provided to the McMaster University
placement coordinator prior to the commencement of the work placement.
Declaration:
I have read and understand that WSIB or private insurance coverage will be provided through
the Ministry of Advanced Education & Skills Development while I am on an unpaid placement as
part of an Approved Program.
I agree that, over the course of my placement, I will participate in and implement all safety-
related training and procedures obtained from the University and the Placement Employer. I will
provide the University with written confirmation that I have received safety training.
I will promptly inform my Placement Employer of any safety concerns. If these concerns are not
resolved, I will contact the University’s placement coordinator within my faculty and notify them
of any unresolved safety concerns.
I understand that all accidents sustained while participating in an unpaid work placement must
be immediately reported to the Placement Employer and my McMaster University placement
coordinator. A MAESD Postsecondary Student Unpaid Work Placement Workplace Insurance
Claim form must be completed and signed in the event of injury and submitted to the University
placement coordinator.
September 2017 Page 2 of 2
I consent to the release of my personal information relating to the placement to my Placement
Employer and MAESD, including address, telephone number, date of birth and social insurance
number.
In the event of an injury, I also agree to maintain regular contact with the University and to
provide the University with information relating to any restrictions and my ability to return to the
placement.
I understand the implications and have had any questions answered to my satisfaction.
Student Name:
Student Signature:
Program Name:
Date:
Organization:
Total Placement Hours:
Visa Student?
YES
NO
Parent/Legal Guardian’s Name (for student less than 18 years of age) please print:
Parent Signature:
Date:
Collection Notice Regarding Personal Information
McMaster University protects your privacy and Personal Information. The Personal Information
requested on this form is collected under the authority of The McMaster University Act, 1976, in
accordance with the Freedom of Information and Protection of Privacy Act (“FIPPA”). The
information will be used to communicate with the Placement Employer for example, to confirm
eligibility for the Placement or in the event of a workplace accident. Direct any questions about
this collection to Privacy Office (University Secretariat) at McMaster University at 905 525 9140
x24337, privacy@mcmaster.ca or visit the website at http://www.mcmaster.ca/privacy/
.
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