Can I submit the form electronically?

Yes if the insurer or regulatory body accepts electronic filings. In the United States, electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted; confirm the recipient accepts e-submissions.

Who must sign the form?

An authorized employer representative or an agent with written authority must sign. Include contact information so the insurer can verify signatory authority if required.

What supporting documents are required?

Attach payroll records, job descriptions, or contracts that substantiate requested changes. Missing documentation is the most common cause of processing delays.

How do I correct an error after submission?

Contact the insurer immediately and submit an amended form or a written correction, signed by an authorized person. Keep the original submission and the correction for audit trails.

Are witnesses or notarization needed?

Not typically required for optional insurance changes, but specific jurisdictions or insurers may request notarization or witness signatures; check recipient requirements before submitting.

What if the insurer rejects the change?

You will receive a decision notice with reasons; respond promptly with additional documentation or file an appeal according to insurer procedures and stated timelines.

Electronic Signature
Templates
Insurance
WSIB Optional Insurance Request Change Form

WSIB Optional Insurance Request Change Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Optional Insurance Request/Change

Mail To:
200 Front Street West
Toronto ON M5V 3J1

Please complete this section.

Account No.

Firm No.

Telephone Enquiry Number

416-344-1000
1-800-387-0750

If you are requesting optional insurance or changing the amount of existing optional insurance, please:

complete the sections A and B (for new requests) or C (for changes)
provide proof of earnings (see below)
have the applicant review and sign the Optional Insurance Declaration (attached)
have the Owner's Certification completed and signed (see page 2)

Individuals who are canceling their optional coverage must complete section D, or forward their request in writing to their local WSIB office.

The WSIB accepts the following documents as proof of earnings, issued by the owner or authorized officer responsible for this account:

For Executive Officers

T4s and T4As or any other document submitted to Canada Revenue Agency (CRA) to report earnings.

For Independent Operators, Sole Proprietors and Partners

Audited financial statements prepared by a professionally designated accountant
Income tax returns with supportive income statements (T1, T2125, T2032, etc.) or other documents submitted to Canada Revenue Agency to report business income.

If the applicant's company has been in business for less than one (1) year, the amount of coverage for premium and benefit purposes is set at 1/3 of the annual maximum insurable earnings.
If the applicant's company has been in business for more than one (1) year, the amount of coverage for premium and benefit purposes must accurately reflect the applicant's actual annual earnings, as supported by documents listed above.
Coverage will not be provided if your operation shows a net business loss.
Loss of earnings benefits are not paid if your operation shows a net business loss, despite active optional insurance.

If the level of earnings cannot be substantiated, the WSIB may deny the request for optional insurance.

The WSIB may deny coverage (or coverage renewal) or cancel coverage in the absence of acceptable proof of earnings.

Any change to the amount of optional insurance will take effect on the date the signed request and satisfactory proof of earnings are received by the WSIB.

The WSIB may require prepayment for optional insurance premiums.

If the applicant is paid benefits at an amount that is lower than the amount of optional insurance, the amount of optional insurance will not be retroactively adjusted.

If you have any questions or require more information, contact your WSIB account representative. If you do not know the phone number, please call the WSIB at the telephone number listed at the top of this form.

A. You must complete this section.

First Name

Middle Name

Last Name

Date of Birth (dd/mmm/yyyy)

Title/Position with Company

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

City

Province

Postal Code

Telephone No.

Date Business Commenced (dd/mmm/yyyy)

B. Complete only if the applicant is requesting new optional insurance.

Amount of Coverage Requested

Today's Date (dd/mmm/yyyy)

Applicant's Signature (must be signed)

C. Complete only if the applicant is requesting a change in the amount of existing optional insurance.

Revised Coverage

Today's Date (dd/mmm/yyyy)

Applicant's Signature (must be signed)

Amount Requested

D. Complete only if the applicant is canceling existing optional insurance.

Name

Today's Date

Signature (must be signed)

Name

Today's Date

Signature (must be signed)

Optional Insurance Declaration

Please read the following information carefully. It explains how Optional Insurance changes your status under the Workplace Safety & Insurance Act ("the Act").

I understand that:

Owners, partners, executive officers and independent operators are not automatically entitled to benefits under the Act.
I am voluntarily requesting to be considered a worker by the WSIB by applying for optional insurance.
I must have optional insurance for a minimum of three (3) consecutive months.
With optional insurance, I am eligible to claim for benefits.
I am giving up my right to sue workers and employers whose industries are covered under Schedule 1 of the Act for damages sustained in a workplace injury.
I must send the WSIB proof of earnings when first requesting optional insurance.
If my earnings level changes, I must send the WSIB a signed request to revise the amount of insurance coverage, along with proof of earnings.
The WSIB may deny my request for coverage if I do not provide acceptable proof of earnings.
The WSIB may request proof of earnings at any time.
The WSIB may adjust the amount of optional insurance that I request.
My optional insurance will continue beyond the minimum three (3) months until either the WSIB or I cancel the insurance.
If I have a workplace injury, my optional insurance will remain in effect until the WSIB receives my signed notification to cancel it.
If I have a workplace injury, my earnings at the time of my injury will be compared to the amount of my optional insurance. The WSIB will base benefits on whichever is the lower amount - my earnings or my optional insurance coverage.
If I am paid benefits at an amount that is lower than the amount of my optional insurance, the amount of my optional insurance will not be retroactively adjusted.
The WSIB may refuse, cancel or deny renewal of my optional insurance if the employer paying for it is in arrears. If any premium is owing on my optional insurance, the amount of the unpaid premium may be deducted from my benefits.
The effective date for new optional insurance requests, changes to or cancellations of optional insurance will either be the date that the completed form 1574A is received by the WSIB, or the requested date, whichever is later.

Applicant's Name

Applicant's Signature

Date (dd/mmm/yyyy)

Owner's Certification

I hereby certify that I am an owner (or authorized officer) responsible for this account. I also certify that the amount of optional insurance requested accurately represents the earnings of the applicant.

I acknowledge that the costs associated with any work-related injuries or occupational diseases for the applicant will be applied to the accident record for this account.

Personal information on this form is collected under the authority of the Workplace Safety and Insurance Act, 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 your WSIB account representative at 416-344-1000 or 1-800-387-0750.

Name of Owner or Authorized Officer

Title

Signature

Telephone

Date Completed (dd/mmm/yyyy)

For Office Use Only:

WSIB Representative

Date (dd/mmm/yyyy)

Amount of Coverage

Effective Date (dd/mmm/yyyy)

Proof of earnings received

Proof of eligibility received

Actual earnings used

1/3 of maximum insurable earnings used

What the WSIB Optional Insurance Request Change Form Is

The WSIB Optional Insurance Request Change Form documents a request to add, modify, or cancel optional workplace insurance coverage tied to a business account. It captures employer identification, account or policy numbers, the scope of the requested change, effective date, and an authorized signature. Organizations use this form to notify the insurer or regulatory body of coverage adjustments that affect premiums, classification, or benefits. Accurate completion helps ensure correct billing, timely administrative processing, and continuity of worker protection while meeting any applicable statutory notice requirements.

Why the Form Matters for Coverage and Compliance

Using the WSIB Optional Insurance Request Change Form helps document consent to coverage adjustments, establishes an administrative record for premium and claims handling, and reduces disputes by creating a clear, dated instruction from an authorized employer representative.

Who Typically Prepares and Signs This Form

Ensure the person completing the form has authority to bind the employer and that their contact information is included for follow-up.

Small business owners and sole proprietors who manage their own payroll and insurance relationships.
HR or payroll managers who coordinate coverage changes across multiple worksites or payroll systems.
Third-party administrators or brokers authorized to submit policy or coverage changes for clients.

Step-by-Step: Completing the Request Form

Follow this sequence to prepare a complete submission and reduce processing time.

01

Gather Identifiers: Collect employer name and account number.
02

Specify Change: Write precise modification details and effective date.
03

Attach Proof: Include supporting payroll or classification documents.
04

Sign and Submit: Authorized signature and chosen delivery method.

Digital Workflow Settings for eSubmission

Configure a clear routing and authentication workflow before sending the form electronically to ensure legal validity and record integrity.

Field	Configuration
Signer Order	Sequential or parallel routing
Authentication	Email link or SMS code
Attachments	Enable PDF, DOCX upload
Audit Trail	Capture IP, timestamp, and actions

Typical eSubmission Flow

A standard electronic submission follows a predictable eight-step path; this condensed flow applies to single-form changes.

Prepare: Complete form and attach documents
Upload: Upload to eSignature or insurer portal
Authenticate: Signer verifies identity
Complete: Signers sign; system stores audit trail

Essential Data Elements Required on the Form

Employer ID: Account or registration number

Business Address: Street, city, state, ZIP

Contact Phone: Primary phone for follow-up

Change Details: Clear description of requested change

Authorized Signer: Name and title

Signature Date: MM/DD/YYYY format

Consequences and Risks of Errors

Processing Delays: Incomplete forms cause slow processing

Coverage Gaps: Incorrect dates may create uninsured periods

Premium Adjustments: Misclassification can change premium liability

Denial of Request: Insufficient proof may result in denial

Regulatory Exposure: Noncompliance penalties may apply

Appeal Complexity: Late corrections complicate appeals

How This Form Differs from Related Documents

Compare the change request to similar filings so you pick the correct form for the intended administrative outcome.

Form Type	Requires Notary	Typical Use
Optional Insurance Change		modify optional coverage
Initial Enrollment	sometimes	new coverage setup
Cancellation Request		terminate optional coverage
Classification Change	sometimes	change payroll classification

eSignature Vendor Pricing and Capabilities for Submitting the Form

Selecting an eSignature provider affects cost, authentication options, and compliance features. The table below summarizes common plan comparisons; confirm vendor details before purchase.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	Varies	Varies

Key Deadlines and Processing Expectations

Be aware of typical timelines so coverage and billing align with the requested effective date.

Effective Date of Change:

Date entered on form; determines billing start

Submission Deadline:

Submit as soon as change is known to avoid retroactive charges

Processing Time:

Insurer processing often takes 2–6 weeks

Appeal Period:

Appeals window varies; check insurer rules

Employee Notice:

Provide required employee notifications if coverage changes affect benefits

Practical Tips for Accurate, Efficient Submissions

Adopt consistent procedures to reduce errors and follow-up requests when filing changes.

Prepare Supporting Documentation

Attach payroll summaries, job descriptions, and prior correspondence to substantiate the requested change and speed review.

Use Standard Formats

Provide dates as MM/DD/YYYY, full legal names, and consistent classification codes to prevent account mismatches.

Confirm Signatory Authority

Verify the signer has authority to bind the employer and include contact details for verification and audit trails.

Prefer eSubmission with Audit Trail

Use an eSignature platform that records timestamps, IP addresses, and signer authentication to support legal validity.

Who Can Legally Sign the Form

Employer Administrator

A senior employee or officer authorized by the company, such as an owner, CEO, CFO, HR director, or payroll manager, who can bind the employer to coverage changes and is listed in corporate authorization records.

Authorized Representative

A broker, agent, or third-party administrator with written authorization or power of attorney to submit and sign the change request on the employer's behalf.

Real-World Submission Examples

Two concise examples show how different organizations complete and use the change form.

Case Study 1

A small manufacturing firm needed to add optional coverage for seasonal staff and updated payroll records to support the change.

The submission included payroll summaries for three months.
The insurer accepted the change effective the requested date after verifying the attached payroll and classification evidence, avoiding retroactive premium adjustments.

Case Study 2

A contractor reclassified several job roles after a project shift and submitted a classification change request with role descriptions.

The request included contracts and wage reports.
After a brief review and one clarifying call, the administrator updated the account, and the corrected classification reduced the employer's premium on the next billing cycle.

Common Preparation Problems to Avoid

Using inconsistent business names or obsolete account numbers that prevent the insurer from matching the submission to the right employer account.
Failing to include an effective date or using ambiguous date formats that create disputes over when coverage begins or ends.
Omitting required supporting documentation, such as payroll records or job descriptions, which often triggers denials or requests for additional information.
Allowing an unauthorized person to sign the form, which can invalidate the request and require resubmission with proper authorization.

Processing Milestones from Submission to Update

Track these numbered milestones to monitor progress and follow up where necessary.

01

1. Submission Received

Insurer acknowledges receipt and assigns a reference number

02

2. Documentation Review

Underwriting or audit team verifies attachments

03

3. Decision Notice

Insurer issues approval, denial, or request for more information

04

4. Account Update

Approved changes appear on billing and policy records

Technical Requirements for eSigning and Sharing

Confirm platform capabilities and file formats before submitting electronically to prevent compatibility or authentication issues.

Formats Supported: PDF, DOCX, and fillable forms
Integrations: Salesforce, NetSuite, Google Workspace
Auth Options: Email, SMS code, KBA

Frequently Asked Questions About the Form and eSubmission

Answers to common questions about who can sign, when eSignatures are valid, supporting documents, and correction procedures.

Need help? Contact support

Can I submit the form electronically?
Yes if the insurer or regulatory body accepts electronic filings. In the United States, electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted; confirm the recipient accepts e-submissions.
Who must sign the form?
An authorized employer representative or an agent with written authority must sign. Include contact information so the insurer can verify signatory authority if required.
What supporting documents are required?
Attach payroll records, job descriptions, or contracts that substantiate requested changes. Missing documentation is the most common cause of processing delays.
How do I correct an error after submission?
Contact the insurer immediately and submit an amended form or a written correction, signed by an authorized person. Keep the original submission and the correction for audit trails.
Are witnesses or notarization needed?
Not typically required for optional insurance changes, but specific jurisdictions or insurers may request notarization or witness signatures; check recipient requirements before submitting.
What if the insurer rejects the change?
You will receive a decision notice with reasons; respond promptly with additional documentation or file an appeal according to insurer procedures and stated timelines.

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