General Industry

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Who should complete this questionnaire?

individuals who believe they may be independent operators
the hiring company or their respective representatives

The individual and the company may submit separate questionnaires if:

they disagree with the answers to some or all of the questions
the individual wants to submit the financial information required to support the answer in the part 3 to us in confidence.

We’ll review your response and notify both the individuals and company of our decision in writing.

Key terms

Workers are entitled to benefits provided by the Workplace Safety and Insurance Act and their employers must pay premiums to the WSIB.

Independent operators can choose to apply for coverage as workers under the Workplace Safety and Insurance Act. If they want insurance, they must pay their own premiums.

Company is the principal or the business that hires the individual.

List two to four companies you’ve entered into a contract for service or business relationship with in the last 18 months:

Name of company	Phone number	Operations
Name of company	Phone number
Name of company	Phone number

Part 1

What type of legal entity do you operate?

Sole proprietorship

Partnership

Corporation

Other

What is your company’s legal name?

What service do you provide for the company?

What is the company’s main business?

Is there a written contract stating the terms of the work relationship?

Yes

Please include a copy of the contract.

One file only.

10 MB limit

Allowed types: pdf, doc, docx, jpg, png.

Do you have a previous or current WSIB account number?

Yes

Please provide WSIB account number

Part 2

Training and supervision

Does an employee of the company train and/or supervise you?

Yes

Do you have to attend meetings and follow specific instructions that indicate the company wants the services performed in a particular way?

Yes

Hours of work

Does the company set the hours and days of work?

Yes

Do you decide your vacation time?

Yes

Order of work

Do you perform services in the order or sequence set by the company?

Yes

Do you report to the company’s office at specified times, follow up on leads and perform tasks at set times?

Yes

Is your work coordinated with the work of others employed by the company?

Yes

Payment

Does the company pay you in regular amounts at stated intervals?

Yes

Does the company decide the amount and payment method?

Yes

Do you receive payment for overtime and statutory holidays?

Yes

Do you receive a T4 income tax slip from the company?

Yes

Does the company pay you according to a standard pay or rate scale?

Yes

Licenses

Does the company hold the licenses (if required) to do the work?

Yes

Serving the public

Do you make your services available on behalf of or as a representative of the company?

Yes

Do you invoice customers on the company’s behalf?

Yes

Do you file HST returns?

Yes

Do you invoice the company for materials used to complete the work?

Yes

Do you wear a uniform that has the company’s name, colours or logo on it?

Yes

Please provide your website address

Are you registered as a business with the Ministry of Public and Business Service Delivery?

Yes

Collective agreement

Do the terms of a collective or union agreement govern the relationship?

Yes

Part 3

What assets (including labour, materials, tools and equipment) are required to do this work?

Beside each of the assets listed, please state the approximate value of each item or its cost in dollars per month.

Do you own 80 per cent or more of the equipment (i.e., business vehicle, tools, computer, etc.) necessary to do the work?

Yes

What costs are incurred in doing the work? This includes the costs of the acquisition, maintenance, operation and repair of assets, as well as financing and loan arrangements with respect to the work and licensing and insurance fees.

Do you pay for these expenses?

Yes

Part 4

Hiring, supervising and paying assistants

Do you hire, supervise and pay workers at the company’s direction (i.e., act as a supervisor or representative of the company)?

Yes

Can the company hire, discipline or fire these support staff?

Yes

Do you pay the support staff directly?

Yes

Doing the work on company premises

Does the company own or control the site where the work is performed?

Yes

Oral and written reports

Do you have to submit regular oral or written reports to the company?

Yes

Right to terminate

Can you end your relationship with the company at any time?

Yes

If your work is unsatisfactory, who has to correct it?

If additional work has to be done to correct or improve a job, do you have to accept these costs or any other losses due to poor workmanship?

Yes

Working for more than one firm at a time

Are you engaged in work for more than one company at the same time?

Yes

Does your contract with the company prohibit you from working with others?

Yes

Declaration

To the best of my knowledge, information and belief, the information provided is true.

I/we understand the WSIB reserves the right to audit and verify these responses. If these responses don’t truly represent the nature of the working relationship, the WSIB may reverse the determination of status retroactively to the date that the working relationship began.

By submitting this form, the individual acknowledges that if they experience a work-related injury or illness, they won’t be eligible for any WSIB benefits unless they request optional insurance coverage and the WSIB approves it.

Personal information on this form is collected under the authority of the Workplace Safety and Insurance Act and may be used to register/determine your status for coverage and to administer to enforce the act.

First name

Last name

Email address

Date

Street address

City

Province

Postal code

Phone number

Principal validation

We’ll send a copy of this completed questionnaire to the principals you provide. They’ll have two business days to validate this form. If we don’t receive a response within two business days, we’ll adjudicate the questionnaire with a decision.

Principal name

Email address

Position

WSIB account number

Please email us at employeraccounts@wsib.on.ca or send us a message through our online services if you have any questions.