Fillable WSPS Health and Safety Excellence program APPLICATION FORM (Workplace Safety & Prevention Services)

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WSPS Health and Safety Excellence program APPLICATION FORM (Workplace Safety & Prevention Services)

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Country of origin: CANADA
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1
620-ARS-01-CGOT
WSPS Health and Safety Excellence program
WSPS Health and Safety Excellence program
APPLICATION FORM
Submit electronic application to: excellenceprogram@wsps.ca
Firm (full name):
Parent Company (if any):
WSIB Account Number*: How many locations are covered
by this WSIB Account Number?*
Predicability Level (if known):
   LOW (equal to or less than 20%)
   HIGH (greater than 20%)
Annual WSIB Premiums: Number of Employees:
Address:
City/Town: Province: Postal Code:
Contact Name (please print): Contact Title:
Telephone Number: Email Address:
* Firms are required to implement all chosen topics at every location covered by the account.
Registration Fees
Prices are per WSIB account number. Complete one application for each WSIB account number. Registration
fees are based on the amount of premiums a firm paid in the prior year. Please check o the appropriate fee
category, based on your premium amounts.
Small Firm
<$100,000 in WSIB premiums
  $800 +HST
Medium Firm
$100,000 - $1M in WSIB premiums
  $1,700 +HST
Large Firm
>$1M in WSIB premiums
  $2,500 +HST
2
620-ARS-01-CGOT
WSPS Health and Safety Excellence program
WSPS Health and Safety Excellence program
Payment Methods:
   Cheque (made payable to Workplace Safety & Prevention Services)
   P.O. # ____________________________     Invoice (approved credit only)
   Credit Card*
   Contact Name: ____________________________________  Telephone #: ______________________
   * If you would like to pay by credit card, please provide a contact name and telephone number.
A WSPS representative will call to obtain your credit card information.
All applications received will be reviewed by WSPS and you will be notified once your application has been
accepted. All fees are non-refundable once activation of the WSIB digital platform occurs, if a firm chooses
to leave the program, or if a firm is removed as a result of non conformance to the code of conduct or WSIB
employer guidelines. There will be no recognition given to firms who leave or are removed from the program.
Included in your Registration Fee:
Orientation meetings and topic sessions facilitated by Health and Safety professionals
One-on-one guidance from a WSPS representative through the program cycle
Access to the members website with a variety of tools and resources
One site visit prior to evidence submission to the WSIB
Excellence program members and their employees are entitled to receive a 10% discount on selected
courses, conferences, workshops and consulting services
3
620-ARS-01-CGOT
WSPS Health and Safety Excellence program
WSPS Health and Safety Excellence program
Terms and Conditions of Participation
1. Employers must submit a completed application to WSPS to be registered into the Excellence program.
2. Employers applying to participate in the Excellence program must have an active account in good standing with WSIB.
An employer that experiences a traumatic fatality will be disqualified during that year from participating in the rebate.
3. Employers can only register with one Program Provider, and cannot switch during their 12 month cycle, unless
approved by WSIB.
4. Employers participating in the Excellence program are required to select one to five topics annually from the
36 topics, as set out in the program guidelines.
5. Employers must complete a needs assessment the first year they participate in the Excellence program; completion
in subsequent years is voluntary.
6. Employers are required to submit evidence to demonstrate they have implemented their chosen topic(s) within
11 months of submission of action plan.
7. Employers must maintain a point of contact with WSPS. If there are any changes, WSPS must be notified.
8. Employers are encouraged to participate in networking activities with other group members.
9. All evidence submitted by the employer will be reviewed by WSIB, with some employers being selected for an
on site validation. If selected, employers must allow WSIB access to all locations under the account number.
10. An employer who declines to participate in an on site validation will not receive any recognition; financial or
non-financial.
11. Employers will only be validated on the topics that evidence is submitted for; if topics are being dropped, the
employer must notify WSPS.
12. Employers and their employees may be asked to participate in questionnaires or surveys as part of the ongoing
Health and Safety Excellence program evaluation.
13. Employers are required to adhere to the Excellence program requirements as outlined in the program guidelines,
current edition.
Company Name:
Owner/Senior Manager Name:
Title:
Email:
*Signature:                                        Date:
*Typed name is equivalent to signature.
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WSPS Health and Safety Excellence program APPLICATION FORM (Workplace Safety & Prevention Services)

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Completed 24 April 2021

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