Indicates required field Online or print request and pay online print and mail-in payment By mail or in person (at any WSIB location): To submit a Freedom of Information request by mail or in person, fill out this request form, print it (using the browser’s print function – shortcut: CTRL+P), and mail or hand deliver it, along with the mandatory $5.00 application fee made payable to the Workplace Safety and Insurance Board. Workplace Safety and Insurance Board 200 Front Street West Privacy and FOI Office, 21st floor Toronto, ON M5V 3J1 What is the request for? access to general records access to own personal information Last name First name Claim number(s) Company name Address (Street/Apt. No./P.O. Box/R.R. No.) City/Town Province Postal code Telephone Email Are you requesting on behalf of yourself? yes no Please provide the name of the client or person on behalf of whom you are acting as a representative Note: We may contact you to verify identity or confirm that you have consent to act as an agent or representative. Description of the records or personal information you are requesting. Please be as specific as possible, including dates. Preferred method of access to records: examine original receive copy Date Signature You can type in your name for the online submission signature To submit Freedom of Information request by mail or in person, fill out this request form, print it (use the browser's print function or the keys Ctrl P) , and mail or hand deliver it, along with a $5.00 application fee (in cash or made payable to the WSIB) to: Workplace Safety and Insurance Board 200 Front Street West Privacy and FOI Office, 21st floor Toronto, ON M5V 3J1 Personal Information collected from this form is in agreement with the Freedom of Information and Protection of Privacy Act (FIPPA) and will be used for the purpose of responding to your request. Questions about the collection of personal information should be directed to our Privacy and Freedom Information Office. Once the form is submitted you'll be directed to a third-party site for payment. Leave this field blank
