WSIB Form 7 "Employer's Report of Injury Disease" - Ontario, Canada

What Is WSIB Form 7?

WSIB Form 7, Employer's Report of Injury/Disease, is an official statement prepared by Ontario employers that need to inform the authorities about the occupational illness or injury. Once you learn about the workplace incident, find out what kind of healthcare was offered to the employee, whether they earn less now or require to work in a different capacity for a time. A WSIB Form 7 fillable version was released on January 1, 2011, and can be downloaded through the link below.

Alternate Name:

  • WSIB Claim Form 7.

The Ontario Workplace Safety and Insurance Board (WSIB) will provide eligible workers with benefits after their employer completes Form 7 and the employee, in their turn, submits WSIB Form 6, Worker's Report of Injury/Disease, to share their own version of events.

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How to Fill Out WSIB Form 7?

Follow these steps to complete WSIB Claim Form 7:

  1. Provide information about the employee - their job title, length of time they have worked for you, social insurance number, and worker reference number. Check the appropriate box to indicate whether they are an executive, elected official, company owner, or relative. Write down the employee's name, address, telephone number, date of birth, sex, preferred language, and date of hire. If they belong to a union, the form must confirm that fact.
  2. Describe the organization you represent - state its trade and legal names, contact details, business activity, and account number.
  3. Outline the details of the injury or illness - when and where it happened, who has learned about it first, which body part was injured. Use free space to elaborate on the incident - for instance, there might be other employees involved or there are witnesses who can confirm the accident actually took place. You can attach your personal statement to the report if you have any concerns about the claim.
  4. If the worker had any kind of medical treatment after the incident, state whether they went to a hospital or got help in the workplace.
  5. If the employee could not work for some time and lost earnings due to the injury or illness, indicate the amount of time they were unable to be present at work.
  6. Check the applicable boxes to describe the specifics of the employee's return to work.
  7. Provide the worker's wage information - state whether they are working full-time or part-time, how much money they receive per hour, day, or week, and what other earnings they receive from your organization.
  8. Write down the details of the current work schedule the worker maintains.
  9. Certify all the statements in your report are true and complete, record your name, title, and telephone number, sign and date the form. Make sure all the pages show the worker's full name and social insurance number. If you want to share additional information with the WSIB, you can do so using the last page of the document.
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Did you know that you can
securely file form 7 online
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eForm7 offers a fast, effective solution for
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Please note: Submitting a No Lost Time claim?
Only complete sections A to D, E (#1) and J.
...go to fillable PDF
Did you know that you can
securely file form 7 online
with our eServices?
eForm7 offers a fast, effective solution for
managing your Form 7 reports with the WSIB.
New features to our eForm 7 makes reporting
online even quicker and easier. Take our new
and improved eForm 7
video
tour.
To submit an eForm 7, visit our
eServices
site. It only
takes a few minutes to subscribe and you can start
filing your reports right away.
Please note: Submitting a No Lost Time claim?
Only complete sections A to D, E (#1) and J.
...go to fillable PDF
7
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Mail To:
OR Fax To:
Employer's Report
200 Front Street West
416-344-4684
of Injury/Disease (Form 7)
Toronto ON M5V 3J1
OR 1-888-313-7373
Claim Number
Please PRINT in black ink
A. Worker Information
Job Title/Occupation (at the time of accident/illness - do not use abbreviations)
Length of time in this position
Social Insurance Number
while working for you
Start >
if
Please check
this worker is a:
executive
elected official
owner
spouse or relative of the employer
Is the worker covered by a
Worker Reference Number
Union/Collective Agreement?
Last Name
First Name
yes
no
Worker's preferred language
dd
mm
yy
Date of
Address (number, street, apt., suite, unit)
Birth
English
French
Other
Telephone
City/Town
Province
Postal Code
dd
mm
yy
Sex
Date of
M
F
Hire
Fold here for
B. Employer Information
?
#10 envelope
Trade and Legal Name (if different provide both)
Check
Provide Number
OR
Firm
Account
one:
Number
Number
Mailing Address
Rate Group Number
Classification Unit Code
City/Town
Postal Code
Telephone
Province
Description of Business Activity
FAX Number
Does your firm have 20 or
more workers?
yes
no
Branch Address where worker is based (if different from mailing address - no abbreviations)
City/Town
Province
Alternate Telephone
Postal Code
C. Accident/Illness Dates and Details
dd
mm
yy
1.
2.
Date and hour of
Who was the accident/illness reported to? (Name & Position)
AM
accident/Awareness
PM
of illness
dd
mm
yy
Telephone
Ext.
Date and hour reported
AM
to employer
PM
3.
Was the accident/illness:
4.
Type of accident/illness: (Please check all that apply)
Sudden Specific Event/Occurrence
Fall
Slip/Trip
Struck/Caught
Gradually Occurring Over Time
Overexertion
Harmful Substances/Environmental
Motor Vehicle Incident
Occupational Disease
Repetition
Assault
Fatality
Fire/Explosion
Other
5.
Area of Injury (Body Part) - (Please check all that apply)
Right
Right
Left
Right
Right
Left
Left
Left
Head
Teeth
Upper back
Face
Neck
Lower back
Shoulder
Wrist
Hip
Ankle
Hand
Arm
Thigh
Foot
Eye(s)
Chest
Abdomen
Ear(s)
Pelvis
Elbow
Finger(s)
Toe(s)
Knee
Forearm
Lower Leg
Other
6.
Describe what happened to cause the accident/illness and what the worker was doing at the time (lifting a 50 lb. box, slipped on wet floor, repetitive movements,
etc. . .). Include what the injury is and any details of equipment, materials, environmental conditions (work area, temperature, noise, chemical, gas, fumes, other
person) that may have contributed. For a condition that occurred gradually over time, please attach a description of the physical
activity required to do the work.
Page 1 of 4
A guide to complete this form is available at www.wsib.on.ca
Page 1 of 3
0007A (01/11)
next page
7
Employer's Report
print
of Injury/Disease (Form 7)
Claim Number
Please PRINT in black ink
Social Insurance Number
Worker Name
(Continued)
C. Accident/Illness Dates and Details
7.
Specify where (shop floor, warehouse, client/customer site, parking lot, etc..).
Did the accident/illness happen on the employer's
premises (owned, leased or maintained)?
yes
no
Start >
yes,
8.
If
where (city, province/state, country).
Did the accident/illness happen outside the Province
of Ontario?
yes
no
yes,
9.
If
provide name(s), position(s), and work phone number(s).
Are you aware of any witnesses or other employees
involved in this accident/illness?
1.
yes
no
2.
10.
yes,
Was any individual, who does not work for your firm,
If
please provide name and work phone number
partially or totally responsible for this
accident/illness?
yes
no
yes,
If
please explain
11.
Are you aware of any prior similar or related problem,
injury or condition?
yes
no
12.
If you have concerns about this claim, attach a written submission to this form.
submission attached
D. Health Care
dd
mm
yy
dd
mm
yy
2.
1.
When did the employer learn that the worker
Did the worker receive health care for this injury?
received health care?
yes,
yes
no
If
when :
3.
(Please check all that apply)
Where was the worker treated for this injury?
On-site health care
Ambulance
Emergency department
Admitted to hospital
Health professional office
Clinic
Other:
Name, address and phone number of health professional
or facility who treated this worker (if known)
E. Lost Time - No Lost Time
1.
Please choose one of the following indicators. After the day of accident/awareness of illness, this worker:
Returned to his/her regular job and has not lost any time and/or earnings. (Complete sections G and J).
Returned to modified work and has not lost any time and/or earnings. (Complete sections F, G, and J).
Has lost time and/or earnings. (Complete ALL remaining sections).
dd
mm
yy
dd
mm
yy
regular work
υ
υ
Provide date worker first lost time
Date worker returned to work (if known)
modified work
2.
This Lost Time - No Lost Time - Modified Work information was confirmed by:
Telephone
Ext.
Myself
Other
Name
F. Return To Work
2.
3.
yes,
1.
Has modified work been
Has modified work been
If
was it
Have you been provided with work
Accepted
Declined
limitations for this worker's injury?
discussed with this worker?
offered to this worker?
If Declined please attach a copy of
yes
no
yes
no
yes
no
the written offer given to the worker.
4.
Who is responsible for arranging worker's return to work
Telephone
Ext.
Myself
Other
Name
Page 2 of 4
Page 2 of 3
0007A (01/11)
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7
Employer's Report
print
of Injury/Disease (Form 7)
Claim Number
Please PRINT in black ink
Worker Name
Social Insurance Number
- (Do not include overtime here)
G. Base Wage/Employment Information
1.
Is this worker (Please check all that apply)
Owner Operator or
Start >
Permanent Full Time
Casual/Irregular
Student
Registered Apprentice
(Sub) Contractor
Permanent Part Time
Seasonal
Unpaid/Trainee
Optional Insurance
Temporary Full Time
Contract
Other
Temporary Part Time
2.
Regular rate of pay
$
per
hour
day
week
other
H. Additional Wage Information
1.
2.
Provide
Net Claim Code
Vacation pay
or Amount
- on each cheque?
percentage
%
Federal
Provincial
yes
no
3.
4.
5.
Date and hour last worked
Normal working hours on
Actual earnings for
6.
Normal earnings for
last day worked
last day worked
last day worked
dd
mm
yy
From
To
AM
AM
AM
$
$
PM
PM
PM
7.
Advances on wages:
If yes, indicate:
yes
no
Full/Regular
Other
Is the worker being paid while he/she recovers?
8.
Other Earnings (Not Regular Wages): Provide the total of additional earnings for each week for the 4 weeks before the accident/illness.
*
For Rotational Shift workers - If the shift cycle exceeds 4 weeks,
Use these spaces for any other earnings
θ
please attach the earnings information for the last complete shift
(indicate Commission, Differentials, Premiums,
cycle prior to the date of accident/illness.
Bonus, Tips, In Lieu %, etc..).
Mandatory
Voluntary
From Date
To Date
Period
Commission
Commission
Commission
Commission
(dd/mm/yy)
(dd/mm/yy)
Overtime Pay
Overtime Pay
$
$
$
$
$
$
Week 1
Week 2
$
$
$
$
$
$
$
$
$
$
$
$
Week 3
Week 4
$
$
$
$
$
$
I. Work Schedule
(Complete either A, B or C. Do not include overtime shifts)
υ
Example: Monday to Friday, 40 hours
(A.) Regular Schedule - Indicate normal work days and hours.
S M T W
T
F
S
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
8
8 8
8
8
or,
(B.) Repeating Rotational Shift Worker - Provide
NUMBER OF
NUMBER OF
HOURS
NUMBER OF WEEKS
DAYS ON
DAYS OFF
PER SHIFT(s)
IN CYCLE
υ
Example: 4 days on, 4 days off, 12 hours per shift, 8 weeks in cycle.
or,
(C.) Varied or Irregular Work Schedule
- Provide the total number of regular hours and shifts for each week for the 4 weeks
prior to the accident/illness. (Do not include overtime hours or shifts here).
Week 1
Week 2
Week 3
Week 4
/
/
/
/
From/To Dates (dd/mm/yy)
Total Hours Worked
Total Shifts Worked
J. It is an offence to deliberately make false statements to the Workplace Safety and Insurance Board.
I declare that all of the information provided on pages 1, 2, and 3 is true.
Name of person completing this report (please print)
Official title
dd
yy
mm
Signature
Telephone
Ext.
Date
Please print form & sign before returning to the WSIB
THE WORKPLACE SAFETY AND INSURANCE ACT REQUIRES YOU GIVE A COPY OF THIS FORM TO YOUR WORKER
Page 3 of 4
Page 3 of 3
0007A (01/11)
next page
7
Employer's Report
of Injury/Disease (Form 7)
Claim Number
Please PRINT in black ink
Worker Name
Social Insurance Number
K. Additional Information
Start >
THE WORKPLACE SAFETY AND INSURANCE ACT REQUIRES YOU GIVE A COPY OF THIS FORM TO YOUR WORKER
Page 4 of 4
0007A (01/11)
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