October 2018 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 Training, Colleges and Universities (MTCU),
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.)
MTCU 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 the University of Guelph will be required to disclose personal information
relating to the unpaid work placement and any WSIB claim or Chubb claim to MTCU.
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 University of Guelph
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 Training, Colleges and Universities 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 University of Guelph placement
coordinator. A MTCU 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.
I consent to the release of my personal information relating to the placement to my Placement
Employer and MTCU, including address, telephone number, date of birth and social insurance
number.
October 2018 Page 2 of 2
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
The University of Guelph protects your privacy and Personal Information. The Personal
Information requested on this form is collected under the authority of the Act To Incorporate The
University of Guelph, 1964 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 the Occupational health & Wellness
Service Associate of the Occupational Health & Wellness department at the University of
Guelph at 519-824-4120 ext. 52647 or visit the website at https://www.uoguelph.ca/hr/hr-
services/occupational-health-wellness/students-unpaid-work-placements-program.
click to sign
signature
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