Wsib Form 6 - Worker'S Report Of Injury/disease
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Mail To:
OR Fax To:
6
Worker's Report
200 Front Street West
416-344-4684
of Injury/Disease (Form 6)
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Toronto ON M5V 3J1
OR 1-888-313-7373
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A. Worker Information
Page
page
Last Name
First Name
Social Insurance Number
Telephone
Address (number, street, apt., suite, unit)
(
)
City/Town
Province
Postal Code
Alternate/Cell Phone
(
)
Date you
How long have you
Job Title/Occupation (at the time you were hurt)
dd
mm
yy
started
been doing this job
for this employer?
with employer
dd
mm
yy
Only check if you
Date of
executive
elected official
owner
spouse or relative of the employer
are one of the following:
Birth
Sex
Your Preferred Language
Would an interpreter
yes
no
Other
M
F
English
French
be helpful?
If yes, do you consent to the disclosure of verbal claim
Are you a member of a union? Do you authorize your union to represent you
yes
no
file status information to your union representative?
in this claim?
yes
no
yes
no
Provide your Union Name and Local
B. Employer Information
Company/Employer Name
Address
City/Town
Province
Postal Code
Your Immediate Supervisor's Name
Company Telephone
(
)
C. Accident/Illness Dates & Details
1.
Date and hour
dd
mm
yy
2.
Who did you report this accident/illness to? (Name & Position)
AM
of accident/Awareness
PM
of illness
Date and hour reported
dd
mm
yy
Telephone
AM
to employer
PM
(
)
3.
Area of Injury (Body Part) - (Please check all that apply)
Right
Right
Left
Right
Right
Left
Left
Left
Upper back
Head
Teeth
Shoulder
Wrist
Hip
Ankle
Lower back
Face
Neck
Hand
Arm
Thigh
Foot
Eye(s)
Chest
Abdomen
Elbow
Finger(s)
Toe(s)
Knee
Ear(s)
Pelvis
Forearm
Lower Leg
Are you:
Other:
Left Handed
Right handed
Specify where it happened (shop floor, warehouse, client/customer site, parking lot, etc.):
4.
Did the accident/illness happen on
yes
no
the employer's property or work site?
If yes, indicate where
5.
Did it happen outside the Province
yes
no
(city, province/state, country):
of Ontario?
7.
6.
Do you have any prior
Have you hurt this area(s) of your
yes
no
no
yes - In Ontario
yes - Outside Ontario
related WSIB/WCB claims?
body before?
A guide to complete this form is available at
0006A (07/05)
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