Workers Comp Exclusion Form

Workers Comp Exclusion Form Template for Canada

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Key Requirements PROMPT example:

"I need a Workers Comp Exclusion Form for a corporate officer in Ontario who will be excluded from coverage starting March 1, 2025, with emphasis on alternative private insurance requirements."

Document background

The Workers Comp Exclusion Form is a crucial document used in Canadian provinces when eligible workers seek to opt out of mandatory workers' compensation coverage. This form is typically required when workers meet specific criteria for exclusion, such as being independent contractors, corporate officers, or falling under other exempt categories as defined by provincial legislation. The document must comply with the requirements of the relevant provincial Workers' Compensation Board and includes detailed information about the worker and employer, the basis for exclusion, acknowledgment of risks, and declarations regarding alternative insurance coverage. It serves as a legal record of the worker's voluntary withdrawal from workers' compensation protection and their understanding of the associated implications.

Suggested Sections

1. Worker Information: Detailed identification of the worker including full legal name, address, date of birth, and employment details

2. Employer Information: Complete details of the employer including legal business name, address, and WCB account number

3. Basis for Exclusion: Specification of the legal basis for requesting exclusion from workers' compensation coverage

4. Declaration of Independent Status: Confirmation that the worker meets the criteria for independent operator status or other exclusion category

5. Acknowledgment of Rights Waiver: Express acknowledgment that by signing this form, the worker waives rights to workers' compensation benefits

6. Risk Understanding: Statement confirming the worker understands the risks and implications of working without workers' compensation coverage

7. Alternative Insurance: Declaration regarding any alternative insurance coverage the worker has or will obtain

8. Signatures: Space for dated signatures of the worker, employer, and witness

Optional Sections

1. Corporate Officer Declaration: Required when the exclusion is based on the worker's status as a corporate officer or director

2. Family Member Status: Required when the exclusion is based on family relationship to the employer

3. Industry-Specific Declarations: Additional declarations required for specific industries like construction or transportation

4. Multiple Employer Declaration: Required when the worker provides services to multiple employers

5. Temporary Worker Status: Required for seasonal or temporary workers seeking exclusion

Suggested Schedules

1. Schedule A - Proof of Independent Business: Documentation proving independent business status (business registration, GST number, etc.)

2. Schedule B - Insurance Certificate: Proof of alternative insurance coverage if applicable

3. Schedule C - Risk Acknowledgment Checklist: Detailed checklist of specific risks and implications being acknowledged

4. Appendix 1 - Provincial Requirements: Specific requirements and conditions for exclusion in the relevant province

5. Appendix 2 - Information Sheet: Educational material explaining the implications of workers' compensation exclusion

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Construction

Technology

Professional Services

Transportation

Real Estate

Consulting

Manufacturing

Healthcare

Agriculture

Media and Entertainment

Retail

Financial Services

Relevant Teams

Human Resources

Legal

Risk Management

Compliance

Operations

Finance

Administration

Executive Leadership

Relevant Roles

Independent Contractor

Corporate Officer

Company Director

Business Owner

Self-Employed Professional

Consultant

Freelancer

Project Manager

Executive Officer

Board Member

Partner

Sole Proprietor

Professional Service Provider

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