Optional insurance request/change

indicates required field

Requesting or changing optional insurance

You need to provide proof of earnings

We accept the following documents (issued by the owner or authorized officer responsible for the account) as proof of earnings:

For executive officers:

T4s and T4As or any other document submitted to the Canada Revenue Agency (CRA) to report earnings.

For sole proprietors and partners:

Audited financial statements prepared by a professional designated accountant.
Income tax returns with supportive income statements (T1, T2125, T2032, etc.) or other documents submitted to the CRA to report business income.

Please note:

If the sole proprietor or partnership has been in business for less than one year, the amount of coverage for premium benefit purposes is set at one-third of the annual maximum insurable earnings.
If the executive officer’s company has been in business for less than one year, the amount of coverage for premium and benefit purposes is set at one-third of the annual maximum insurable earnings or the amount stated on the optional insurance form.
If the applicant’s company has been in business for more than one year, the amount of coverage for premium and benefit purposes must accurately reflect the applicant’s actual annual earnings, as supported by the documents submitted.
Coverage won’t be provided if your operation shows a net business loss.
Loss of earnings benefits aren’t paid if your operation shows a net business loss despite active optional insurance.
We may deny the request (or coverage renewal) for optional insurance if the applicant can’t substantiate their level of earnings.

Any new requests for optional insurance or changes to the amount of optional insurance will take effect on the date we receive the completed form and satisfactory proof of earnings. We require pre-payment for optional insurance premiums.

The amount of optional insurance won’t be retroactively adjusted if the applicant receives benefits at an amount that is lower than the amount of optional insurance.

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

Optional insurance change/request form

I’m requesting optional insurance

I’d like to change my existing optional insurance amount

I’d like to cancel my existing optional insurance

First name

Last name

Date of birth

Title/position with company

Street address

City

Province

Postal code

Phone Number

Date business commenced

Amount of coverage request

Date

Phone Number

Date business commenced

Revised coverage amount requested

Date

Name of person	Date	Operations
Name of person	Date

Optional insurance declaration

Please read the declaration information carefully. It explains how optional insurance changes your status under the Workplace Safety and Insurance Act (the Act).

I understand that:

Owner, partners, executive officers and independent operators are not automatically entitled to benefits under the Act, unless they are included in expanded compulsory coverage in construction.
I am voluntarily requesting to be considered a worker by the WSIB by applying for optional insurance as I am exempt from WSIB mandatory coverage.
I must have optional insurance for a minimum of three consecutive months.
With optional insurance, I am entitled to all benefits workers receive.
I am giving up the right to sue workers and businesses whose industries are covered under Schedule 1 of the Act for damages sustained in a workplace injury.
I must send the WSIB proof of earnings when first requesting optional insurance.
If my earnings level changes, I must send the WSIB a signed request to revise the amount of insurance coverage, along with proof of earnings.
The WSIB may deny my request for coverage if I do not provide proof of earnings.
The WSIB may request proof of earnings at any time.
The WSIB may adjust the amount of optional insurance that I request.
My optional insurance will continue beyond the minimum three months until either the WSIB or I cancel the insurance.
If I have a workplace injury, my optional insurance will remain in effect until I notify the WSIB, in writing, that I wish to cancel it or that my status has changed to mandatorily covered.
If I have a workplace injury, my earnings at the time of my injury will be compared to the amount of my optional insurance. The WSIB will base benefits on whichever is the lower amount – my earnings or my optional insurance coverage.
If I am paid benefits at an amount that is lower than the amount of my optional insurance, the amount of my optional insurance will not be retroactively adjusted.
The WSIB may cancel or deny renewal of my optional insurance if the business paying for it has amounts owing, or the WSIB determines I am mandatorily covered under the Act. If any premiums are owning on my optional insurance, the amount of the unpaid premium may be deducted from my benefits.
The effective date for new optional insurance requests, changes to or cancellations of optional insurance will either be the date that the completed optional insurance request/change form is received by the WSIB, or the requested date, whichever is later.
If the WSIB determines I am mandatorily covered, the effective date of changes to, or cancellation of, my optional insurance may be made retroactively.

Applicant’s name

Applicant’s email

Date

Owner’s certification

I hereby certify I’m an owner (or authorized officer) responsible for this account. I also certify that the amount of optional insurance requested accurately represents the earnings of the applicant.

I acknowledge that the accident costs associated with any work-related injuries for the applicant will be applied to the accident record for this account.

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

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

Name of owner or authorized officer

Title

WSIB account number

Email address

Phone number

Date completed

Attach financial documents

One file only.

10 MB limit

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