WSIB Form

Last Name

First Name

Claim File No.

Street No.

Street Name

Apt./Suite No.

Town/City

Province

Postal Code

Country

Telephone

Date of Birth

Date of Injury/Illness

Please choose one option: Please choose one option: I am requesting that a copy of my claim file be sent to me at the above address. I am requesting that a copy of my claim file be sent to a third party listed below. (Please complete section below)

Signature of Worker

Date