C1040 - Election To Claim Under The Ab Wcb - Workers' Compensation Board printable pdf download

C1040

ELECTION TO CLAIM UNDER THE AB WCB

Workers’ Compensation Board

Box 2415

(AB Accident, Out of Province Resident)

Edmonton AB T5J 2S5

In order that we may proceed with this claim, please complete and return this form without delay.

Date of Accident

Claim Number:

(YYYY/MM/DD)

Worker’s Surname

First Name

Initial

Date of Birth

(YYYY/MM/DD)

Address

City/town

Province

Postal Code

Telephone Number

We have information that you reside outside the Province of Alberta but were injured on the date

shown above in a work-related accident within Alberta.

Pursuant to Section 29 of the Workers’ Compensation Act of Alberta (the “WCA”) and Section 4.1 of

the Interjurisdictional Agreement on Workers’ Compensation, you may have

the right to claim compensation under the WCA of Alberta, or alternatively to claim compensation or

another remedy under the law of the place in which you reside.

You should consider this matter carefully and you may wish to contact the workers’ compensation

agency in the province of territory where you reside in order to determine your rights there. If you

decide to claim compensation in Alberta, you should complete the election portion of this form and

return it.

If we have not heard from you within thirty days, we will assume that you do not wish to claim in

Alberta and we will take no further action in this matter.

ELECTION TO CLAIM UNDER THE AB WCB

In the matter of injuries resulting from an accident that happened on ________________________ at

or near _______________________________ I elect to claim compensation under the Workers'

Compensation Act of the Province of Alberta. Should my claim be accepted, I waive and forego any

rights to compensation in any other jurisdiction, and will not apply for or accept any benefits from such

other jurisdiction unless authorized to do so by the Workers’ Compensation Board of Alberta.

have read and understand the provisions of Section 29 of the WCA and Section 4.1 of the

Interjurisdictional Agreement .

Dated this ________________ day of ____________, 20 _____, at _________________

Worker’s Social Insurance Number * ____________________

Signature Worker or Dependent ________________________

Witness Name ________________________________________

Witness Signature _____________________________________

This information is requested in accordance with Section 36 of the Workers’ Compensation Act.

* Optional

*C1040*

C – 1040 REV MAY 2011

C1040 - Election To Claim Under The Ab Wcb - Workers' Compensation Board

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