Toronto Ottawa London Windsor Kitchener Kingston St.

r Kingston St. Catharines North Bay Thunder Bay Hamilton Sudbury Timmins Guelph Sault Ste. Marie

200 Front Street West Telephone: (416) 344−1007 Employer Registration

3 rd Floor Fax: (416) 344−4684
Toronto ON M5V 3J1 Toll Free: 1−800−387−0750 Account Number Firm Number

All information is strictly

180 Kent Street confidential.
Telephone: (613) 237−8840
Suite 400 Fax: (613) 239−3321
Issue Date (dd-mmm-yyyy)
Ottawa ON K1P 0B6 Toll Free: 1−800−267−9601
Mailing Address
Start >
148 Fullarton Street Telephone: (519) 663−2331
7 th Floor Fax: 1−888−313−7373
London ON N6A 5P3 Toll Free: 1−800−265−4752
reset Town/City
P.O. Box 1617 Telephone: (519) 966−0660
Windsor ON Fax: (519) 972−4181 print Province Postal Code
N9A 7B7 Toll Free: 1−800−265−7380

55 King Street West Telephone: (519) 576−4130 Telephone Number Fax Number
3 rd Floor Fax: (519) 576−2667
Kitchener ON N2G 4W1 Toll Free: 1−800−265−2570
Website Address
234 Concession Street Telephone: (613) 544−9682
Suite 304 Fax: (613) 544−1510 Email Address
Kingston ON K7K 6W6 Toll Free: 1−800−267−9461

301 St. Paul Street Telephone: (905) 687−8622

th
8 Floor Fax: (905) 687−7117
Section A : Should You Register?
St. Catharines ON L2R 7R4 Toll Free: 1−800−263−2484
Do you currently hire workers, or (sub)contractors considered by the yes no
WSIB to be workers, or planStreet
128 McIntyre to hire them in
West the future?
Telephone: (705) 472−5200
North Bay ON Fax: (705) 472−9801
If you have answered "yes", how many workers do you generally have?
P1B 2Y6 Toll Free: 1−800−461−9521
Please complete this form.
1113 Jade
If you have answered Court
"no" Telephone:
to the above question, an(807) 343−1710
account may still be established for optional insurance. If you do
Suiteoptional
not wish to request 200 insurance, doFax:
not(807)
fill in343−1702
this form.
Thunder Bay ON P7B 6V3 Toll Free: 1−800−465−3934
Domestic Employers: If you employ a domestic for more than 24 hours a week, complete this form
P.O. Box 2099, Station LCD1
Section B: Previous Registration Telephone: (905) 523−1800
120 King Street West Fax: (905) 521−4576
Do the owner(s), partners or executive
Hamiltonofficer(s)
ON L8Nhave,
4C5 or haveToll
theyFree:
previously had, an account with the WSIB?
1−800−263−8488 yes no
If you have answered "no", go to Section C.
If you have answered "yes", please provide
30 Cedar Street the following information
Telephone: for the previous account. If there is information about more
(705) 675−9301
than one account, please use Sudbury
page 3. ONgo to Page 3 Fax: (705) 675−9367
P3E 1A4 Toll Free: 1−800−461−3350
Legal Name Address
Ontario Government Complex Telephone: (705) 235−6130
Highway 101 East Fax: (705) 235−6140
City P.O. Bag 4020 Province Postal Code
Toll Free: 1−800−461−9856 Telephone Number WSIB Account Number
South Porcupine ON P0N 1H0

Section C: Employer Name(s)

100 Stone&Road
Identification
West Telephone: (519) 826−4650
Please complete this section in
2ndfull.
FloorA copy of the documents
Fax: (519) filed with the Ministry of Consumer and Business Services or any other supporting
826−4678
documents must be attached Guelph
to this ON
form.
N1G 5L3 Toll Free: 1−888−259−4228
Legal Name
153 Great Northern Road Telephone: (705) 942−3002
Sault Ste. Marie ON Fax: (705) 942−7582
Place an "X" in the box that P6B 4Y9Sole Proprietorship Toll Free: 1−800−461−6005 Language Preference
describes the ownership Partnership Corporation Other
of your operation. English French
Trade Name(s)

CCRA No. (Revenue Canada) Bank Name Branch

Section D: Address(es)
Work Location
Please provide the physical location where the employer is carrying on business activities (i.e. not a box number or general delivery).
If there is more than one work location, please use page 3. go to Page 3
Address

Postal Code Area Code Telephone Number Area Code FAX Number Email Address (if different)

Payroll Address
Only fill out this section if the physical location of your payroll records differs from your work location address.
Address

Postal Code Area Code Telephone Number Area Code FAX Number Email Address (if different)

0775A
0775A(12/09)
(06/09) www.wsib.on.ca
go to next page
 Section E: Business Activity
Describe your business activity, including equipment or machinery used and materials contained in your product, in the area below.
Dates Estimated Insurable
(e.g. 01JAN1996) Earnings for For WSIB
Business Activity Description
(Include all workers' and the Current Use Only
contractors' labour) Calendar Year
Date Help First Employed
(ddmmmyyyy)
Start >
Date Help First Employed
(ddmmmyyyy)

Date Help First Employed

(ddmmmyyyy)

If there are more than three business activities, please use page 3. go to Page 3

If there is more than one business activity, do you maintain yes no

segregated payrolls for each business activity?

Please provide the trade names and business activities of three competitors.
Name Business Activity

Section F: Owner/Executive Details

Please provide the following details about the owner, managing partner, or chief executive officer.
First Name Middle Name Last Name

Date of Birth (e.g. 01JAN1995) Title

Home Address (This address must be a physical address and not a box number or a general delivery).

City Province Postal Code Area Code Telephone No.

If the employer has more partner(s) or executive officer(s) than the one individual shown above, please use page 3. go to Page 3

Personal information on this form is collected under the authority of the Workplace Safety and Insurance Act, 1997, and may be used to
register/determine your status for coverage and to administer and enforce the Act. If you have any questions, please call 1-800-387-8638.

Section G: Associated Employer(s)

Does the employer have an associated relationship with one If yes, does the employer have any business dealings
or more other employers? yes no with the associated employer(s)? yes no

If you have answered "yes" to both these questions, please Legal Name
provide the name and address of the associated employer.
If there is more than one employer, please use page 3. go to Page 3
Address City Province Postal Code Account Number

Section H: Certification
I hereby certify that I am the employer (or authorized officer) responsible for paying all WSIB premiums on this account (and any
linked accounts) for which the individual or entity identified under "Legal Name" in Section C is legally liable. To the best of my
knowledge, the information on this form and on any documents attached is true and correct.

Name (please print) Title

Signature Area Code Telephone Number Date Completed (e.g. 01JAN1996)

Please print this document, sign and return to the d d m m m y y y y
Workplace Safety and Insurance Board.

Letters/Forms Issued WSIB Representative Signature

For WSIB
Use Only

0775A2 www.wsib.on.ca
go to Page 3
 Employer Registration
Page 3

All information is strictly confidential. go to HOME page

Legal Name

Start >

0775A3 go to HOME page print reset www.wsib.on.ca