I am (check ( 3 ) one of the following):
A director of a corporation, and guide or control the corporation’s policies and purposes;
An employer; or
Self-employed without workers.
My rate of compensation for my personal optional coverage applications is $
.00.
I ACKNOWLEDGE this is the amount the WSCC will use as my actual rate of compensation.
I will provide acceptable proof of earnings.
Optional coverage required:
Applicant Signature Date
FOR WSCC USE ONLY
Amount of Coverage Effective Dates Authorization
Personal Optional
Coverage Application
Last Name First Name
Company Name Company Position
Mailing Address City/Town Province/Territory Postal Code
Phone Number Fax Number Cell Number
Email NT and/or NU Communities Currently Operating In
Description of Operation
YYDD
MM
YYDDMM
YYDDMM
To
From
RS004 1703
Please complete this form only if you require personal optional coverage.
Return it to the address below.
NOTE: Approved personal optional coverage provides protection under the
Workers’ Compensation Acts, including benefits and immunity from suit provisions.
Head Office: Box 8888 • Yellowknife, NT X1A 2R3 • Telephone: (867) 920-3888 • Toll Free: 1-800-661-0792 • Fax: (867) 873-4596 • Toll Free Fax: 1-866-277-3677
Box 669 • Iqaluit, NU X0A 0H0 • Telephone: (867) 979-8500 • Toll Free: 1-877-404-4407 • Fax: (867) 979-8501 • Toll Free Fax: 1-866-979-8501
employer@wscc.nt.ca • employernu@wscc.nu.ca
wscc.nt.ca • wscc.nu.ca
$
Employer Number
Ce formulaire est disponible en francais
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The WSCC may use this information for the administration of the Workers’ Compensation Acts,
the Safety Acts, and/or the Mine Health and Safety Acts, and their associated Regulations.
The WSCC may use this information for the administration of legislation under our authority, including the Workers’ Compensation Acts, the Safety Acts, and/or the Mine Health and Safety Acts, and their
associated Regulations, and to contact you in relation to the requirements under the relevant legislation. It is your responsibility when providing an email address to ensure reasonable safeguards are in
place to protect the confidentiality and security of your personal information within your email account.
Please print form to sign
