Workers Comp Exclusion Form Template for Canada

This document serves as a formal application and declaration for exclusion from workers' compensation coverage under Canadian provincial legislation. It is designed to comply with the specific requirements of the relevant provincial Workers' Compensation Board or Workplace Safety and Insurance Board. The form captures essential information about the worker and employer, establishes the legal basis for exclusion, and includes necessary acknowledgments and declarations regarding the implications of opting out of workers' compensation coverage. It incorporates provincial-specific requirements and must be completed with full understanding of the legal consequences of exclusion from workers' compensation protection.

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What is a Workers Comp Exclusion Form?

The Workers Comp Exclusion Form is a crucial document used in Canadian provinces when eligible workers seek to opt out of mandatory workers' compensation coverage. This form is typically required when workers meet specific criteria for exclusion, such as being independent contractors, corporate officers, or falling under other exempt categories as defined by provincial legislation. The document must comply with the requirements of the relevant provincial Workers' Compensation Board and includes detailed information about the worker and employer, the basis for exclusion, acknowledgment of risks, and declarations regarding alternative insurance coverage. It serves as a legal record of the worker's voluntary withdrawal from workers' compensation protection and their understanding of the associated implications.

What sections should be included in a Workers Comp Exclusion Form?

1. Worker Information: Detailed identification of the worker including full legal name, address, date of birth, and employment details

2. Employer Information: Complete details of the employer including legal business name, address, and WCB account number

3. Basis for Exclusion: Specification of the legal basis for requesting exclusion from workers' compensation coverage

4. Declaration of Independent Status: Confirmation that the worker meets the criteria for independent operator status or other exclusion category

5. Acknowledgment of Rights Waiver: Express acknowledgment that by signing this form, the worker waives rights to workers' compensation benefits

6. Risk Understanding: Statement confirming the worker understands the risks and implications of working without workers' compensation coverage

7. Alternative Insurance: Declaration regarding any alternative insurance coverage the worker has or will obtain

8. Signatures: Space for dated signatures of the worker, employer, and witness

What sections are optional to include in a Workers Comp Exclusion Form?

1. Corporate Officer Declaration: Required when the exclusion is based on the worker's status as a corporate officer or director

2. Family Member Status: Required when the exclusion is based on family relationship to the employer

3. Industry-Specific Declarations: Additional declarations required for specific industries like construction or transportation

4. Multiple Employer Declaration: Required when the worker provides services to multiple employers

5. Temporary Worker Status: Required for seasonal or temporary workers seeking exclusion

What schedules should be included in a Workers Comp Exclusion Form?

1. Schedule A - Proof of Independent Business: Documentation proving independent business status (business registration, GST number, etc.)

2. Schedule B - Insurance Certificate: Proof of alternative insurance coverage if applicable

3. Schedule C - Risk Acknowledgment Checklist: Detailed checklist of specific risks and implications being acknowledged

4. Appendix 1 - Provincial Requirements: Specific requirements and conditions for exclusion in the relevant province

5. Appendix 2 - Information Sheet: Educational material explaining the implications of workers' compensation exclusion

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Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents

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Generate a Bespoke Document

Download a Standard Workers Comp Exclusion Form

Review your own Workers Comp Exclusion Form

What is a Workers Comp Exclusion Form?

What sections should be included in a Workers Comp Exclusion Form?

What sections are optional to include in a Workers Comp Exclusion Form?

What schedules should be included in a Workers Comp Exclusion Form?

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Alex Denne

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