Employer'S Statement Form
ADVERTISEMENT
1
2Employer’s Statement
Page 1 of 2
identification
Name of Employee: ____________________________________________________________________________________________________
Policy No: ______________________________________________ Social Insurance No: ____________________________________________
eMPLoYee inforMation
1. Employee’s date of hire: _______________________________________________________________________________________________
2. Employee’s status q permanent q temporary q seasonal q part-time q contractual
3 Number of regular hours worked per week: ______________________________________________________________________________
4. Seasonal employees – number of weeks per year:
Check months normally worked:
q January q February q March q April q May q June q July q August q September q October q November q December
5. Gross salary: $ ______________________________ Pay periods per year: q 52 q 26 q 24 q 12
CPP/QPP contribution: $ _________________ CEIC contribution: $ _________________ QPIP contribution: $ _________________
Federal income tax: $ _________________ Provincial income tax: $ _________________
6. Employee position title: ______________________________________________________________________________________________
7. Number of years in this position? _______________________________________________________________________________________
8. Briefly describe this employee’s responsibilities: ___________________________________________________________________________
__________________________________________________________________________________________________________________
9. Is this employee covered under a group or personal insurance plan to which the company subscribes or contributes?
q yes q no If yes, please provide the following information:
Name of Insurer: ____________________________________________________________________________________________________
Group No (if applicable): _____________________ Certificate or Policy No: __________________________________________________
10. Do you pay a portion of the Blue Cross personal insurance premium?
q yes q no
sick Leave inforMation
1. Date of last day worked by employee: ____________________________________________________________________________________
d ay / mont h / year
2. Date of last day paid by employer: _______________________________________________________________________________________
d ay / mont h / year
3. On the date of onset of disability, was the employee: on holiday, laid off, unpaid leave or disciplinary suspension?
q yes q no
If yes, please specify: ____________________________________________________________________________________
__________________________________________________________________________________________________________________
4. Have the responsibilities of this employee been modified recently?
q yes q no
If yes, please specify: ________________________________________________________________________________________________
__________________________________________________________________________________________________________________
5. Had you noticed any change in employee performance or attendance prior to the onset of disability?
q yes q no
If yes, please specify: ________________________________________________________________________________________________
6. Was the disability caused by an accident in the workplace or occupational illness?
q yes q no
If yes, has the employee presented a claim to CSST, WSIB or other workmen’s compensation board?
q yes q no
If yes, please attach a copy of the claim and any related correspondence with the organization(s).
7. If necessary, could you offer: a) a gradual return to work? q yes q no
b) lighter duties? q yes q no
8. Expected date of return to work: ________________________________________________________________________________________
day / mont h / year
9. If employee has already returned to work, please specify date: ________________________________________________________________
day / m ont h / yea r
10. Do you have any doubts about the validity of this claim?
q yes q no
iMPortant: PLease coMPLete reverse of tHis forM
01QRI0011A
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business