Fill and Sign the Property Tax Form 50 260 2011

EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE RESET As an employer, the Workers Compensation Act requires you to submit this report within three days of an injury to one of your workers, even if you disagree with the claim. By submitting your report promptly, you avoid penalties and delays in the adjudication of the claim. Please report using one of the following options: 1. Online — The quickest and easiest option: The online screen application customizes questions to the worker’s injury. You can save your report and update it later with new information. Once submitted, you can follow the status of the claim online. Go to WorkSafeBC.com and select “Report an injury or illness.” 2. Fillable PDF form: Type in your details online, print the form, and submit it by FAX or MAIL. Go to WorkSafeBC.com and select “Report an injury or illness.” 3. Paper form: Clearly PRINT details, sign the form, and submit it by FAX or MAIL. FAX: 604 233-9777 in Greater Vancouver or toll-free within BC at 1 888 922-8807 MAIL: WorkSafeBC, PO Box 4700 Stn Terminal, Vancouver BC V6B 1J1 WorkSafeBC claim number (if known) Employer information Employer’s name (as registered with WorkSafeBC) Type of business WorkSafeBC account number Classification unit number Operating location number Employer address line 1 (mailing) Employer contact last name First name Employer address line 2 (mailing) Employer contact telephone (and area code) City Province/state Employer payroll contact last name Country (if not Canada) Postal code/zip Employer payroll contact telephone (and area code) Extension Employer contact fax (and area code) First name Extension Employer payroll contact fax (and area code) Worker information Worker last name First name Middle initial Date of birth (yyyy-mm-dd) Home phone number (include area code) Social insurance number - Gender M F - Address line 1 Address line 2 City Province/state Country (if not Canada) 1. What is the worker’s occupation? Postal code/zip 2. Has the worker been employed by this firm for less than 12 months? Yes No 3. If yes, start date (yyyy-mm-dd) 4. At the time of injury, was the worker (check all that apply) Permanent Temporary Full time Part time Apprentice Volunteer Student New entrant to workforce Self-employed Principal/partner or relative of employer Fisher Hired on a contract basis Casual Other (please specify) Incident information 5. Date of incident (yyyy-mm-dd) Time of incident (hh:mm) a.m. 7. Did worker report injury or exposure to employer? Yes No ► 9. Name of person reported to p.m. OR 6. Period of exposure resulting in occupational disease (yyyy-mm-dd) To From 8. The injury or disease was first reported to employer on (yyyy-mm-dd) 10. Describe how the incident happened (please check one) To: First aid Supervisor Other (please specify) Office 11. Describe the injury in detail (what part of the body was injured) 12. Side of body injured Left Right Both Not applicable 13. Describe the work incident location (address, city, province) and where incident occurred (e.g. shop floor, lunchroom, parking lot) 14. Did the injury(ies) or exposure result from a specific incident? Yes No 7 W o rk e rs’ C om p e n s a ti o n B o a rd o f B .C. (R02/11) Page 1 of 3 Employer’s Report of Injury or Occupational Disease (continued) If faxing form, please complete this section and fax both sides of page. Missing pages may result in delays in processing. Worker last name Social insurance number First name Middle initial Personal health number (CareCard) Date of incident (yyyy-mm-dd) - Date of birth (yyyy-mm-dd) - 15. Contributing factors — select AT LEAST ONE, and as many as applicable lb kg Lifting Struck Overexertion Repetitive (activity repeated over and over again) Crush Slip or trip Sharp edge Twist Fire or explosion Harmful substances in the work environment Fall 16. Were there any witnesses? Yes No 18. Were the worker’s actions at time of injury for the purpose of your business? Yes No 20. Did the incident happen during the worker’s normal shift? Yes No 22. Did the worker receive first aid? Yes No Date (yyyy-mm-dd) ► 23. Did the worker go to hospital, clinic, or visit a physician or qualified practitioner? Yes No Date (yyyy-mm-dd) ► If yes, please provide provider address (if known) WorkSafeBC claim number (if known) - - Animal bite Assault Motor vehicle accident Unsure/other (please explain below) 17. Did the incident occur in British Columbia? Yes No 19. Did the incident occur on employer’s premises or an authorized worksite? Yes No 21. Was the worker performing their regular duties at the time of the incident? Yes No If yes, please provide first aid attendant name (if known) If yes, please provide provider name (if known) 24. Are you aware of any recent pain or disability in the area of the worker’s reported injury? Yes No 25. Do you have any objections to the claim being allowed? If yes, please explain Yes No ► Wage information 26. Did the worker miss any time from work beyond the date of injury or exposure? Yes No If NO WORK WAS MISSED and NO CHANGE to duties/pay, proceed to bottom of page to sign, date, and submit this report. If WORK WAS MISSED or if duties/pay have been MODIFIED, please answer ALL questions on this form. 27. Provide the base salary amount for this employment position at the time of injury $ Hourly Daily Weekly Monthly Yearly 28. Does worker receive other amounts of compensation 29. in addition to base salary? Yes No Does worker receive vacation pay on every cheque? Yes No If yes, vacation pay __________% Please select check boxes for any of the following amounts worker receives in addition to base salary AND provide the amount for each: Tips and gratuities $_____________ Room and board $_____________ $_____________ Other $_____________ Shift differential Overtime $_____________ If worker is disabled from work, will you continue to pay: Base salary? Yes Other amounts of compensation in addition to base salary? Yes Will worker receive vacation pay on every cheque? Yes If yes, vacation pay __________% No No No Please select check boxes for any of the following amounts worker will continue to receive in addition to base salary AND provide the amount for each: Tips and gratuities $_____________ Room and board $_____________ $_____________ Other $_____________ Shift differential Overtime $_____________ 30. Provide the amount of gross earnings for the past 3 months or 12 weeks prior to the date of injury or exposure $ 3 months 12 weeks 31. Does the worker have a fixed-shift rotation? 32. If no, please explain Yes No 33. If yes, show the normal work week by entering the paid hours 34. Did the worker continue to work past day of injury? Yes No 36. Number of hours scheduled to work on last day worked 7 Sun Mon Tues Wed Thu Fri Sat 35. Last day worked (yyyy-mm-dd) 37. Number of hours worked on last day 38. Number of hours paid by employer on last day worked (R02/11) Page 2 of 3 Employer’s Report of Injury or Occupational Disease (continued) If faxing form, please complete this section and fax both sides of page. Missing pages may result in delays in processing. Worker last name Social insurance number First name Middle initial Personal health number (CareCard) Date of incident (yyyy-mm-dd) - WorkSafeBC claim number (if known) Date of birth (yyyy-mm-dd) - - - Return-to-work information 39. Has the worker returned to work? Yes No 40. If YES: Date (yyyy-mm-dd) No Since the return to work, have the worker’s duties, hours of work, work schedule, and/or rate of pay changed? Yes 41. If NO: Do you have any modified or transitional duties available? 42. If yes, please describe modified or transitional duties Yes No Have the modified or transitional duties been offered to the worker? No Yes ► Signature and report date 43. Employer signature 44. Employer title 45. Date of report (yyyy-mm-dd) For assistance, please call our Claims Call Centre at 604 231-8888 or toll-free within Canada at 1 888 967-5377. Please note: If you have concerns with this claim, please contact the officer handling the claim at the WorkSafeBC office to make known your objections or you may submit a letter detailing your specific concerns. Impartial advice on WorkSafeBC claims — To ensure you have an opportunity to obtain impartial advice on WorkSafeBC claims matters, the BC legislature has provided impartial advisers. Employers’ Advisers are available to provide independent advice or clarification on a WorkSafeBC claim related to your firm. For additional information on the Employers’ Advisers, please refer to their web site at www.labour.gov.bc.ca/eao/. Lower Mainland Kelowna Prince George Victoria 604 713-0303 (Richmond) 250 717-2050 250 565-4285 250 952-4821 Toll free 1 800 925-2233 1 866 855-7575 1 888 608-8882 1 800 663-8783 Personal information on this form is collected for the purposes of administering a worker’s compensation claim by WorkSafeBC in accordance with the Workers Compensation Act and the Freedom of Information and Protection of Privacy Act. For further information about the collection of personal information, please contact WorkSafeBC’s Freedom of Information Coordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or telephone 604 279-8171. 7 (R02/11) Page 3 of 3