St. Catharines

North Bay

Thunder Bay





Sault Ste. Marie

200 Front Street West 3 rd Floor Toronto ON M5V 3J1

Telephone: (416) 344−1007 Fax: (416) 344−4684 Toll Free: 1−800−387−0750

Employer Registration
Account Number Firm Number

All information Kent Street confidential. (613) 237−8840 180 is strictly Telephone:
Issue Date (dd-mmm-yyyy) K1P 0B6 Ottawa ON
Suite 400 Fax: (613) 239−3321 Toll Free: 1−800−267−9601 Telephone: (519) 663−2331 Fax: 1−888−313−7373 Toll Free: 1−800−265−4752

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Mailing Address

148 Fullarton Street 7 th Floor London ON N6A 5P3 P.O. Box 1617 Windsor ON N9A 7B7 55 King Street West 3 rd Floor Kitchener ON N2G 4W1 234 Concession Street Suite 304 Kingston ON K7K 6W6 301 St. Paul Street

Telephone: (519) 966−0660 Fax: (519) 972−4181 print Toll Free: 1−800−265−7380 Telephone: (519) 576−4130 Fax: (519) 576−2667 Toll Free: 1−800−265−2570 Telephone: (613) 544−9682 Fax: (613) 544−1510 Toll Free: 1−800−267−9461 Telephone: (905) 687−8622 Fax: (905) 687−7117 Toll Free: 1−800−263−2484

Town/City Province Telephone Number Website Address Email Address Postal Code Fax Number

8 Floor Section A : Should You Register? St. Catharines ON L2R 7R4

Do you currently hire workers, or (sub)contractors considered by the 128 McIntyre Street West Telephone: (705) WSIB to be workers, or plan to hire them in the future? 472−5200 North Bay ON Fax: (705) 472−9801 If you have answered "yes", how many workers do you generally have? P1B 2Y6 Toll Free: 1−800−461−9521 Please complete this form.



1113 Jade Court Telephone: account may If you have answered "no" to the above question, an(807) 343−1710 still be established for optional insurance. If you do Suite 200 Fax: fill in this form. not wish to request optional insurance, do not(807) 343−1702

Domestic Employers:

Thunder Bay ON P7B 6V3

If you employ a domestic for more than 24 hours a week, complete this form
Telephone: (905) 523−1800 Fax: (905) 521−4576

Toll Free: 1−800−465−3934

P.O. Box 2099, Section B: Previous Registration Station LCD1 120 King Street West

Do the owner(s), partners or executive officer(s) have, or haveToll Free: 1−800−263−8488 they previously had, an account with the WSIB? Hamilton ON L8N 4C5 If you have answered "no", go to Section C.



If you have answered "yes", please provide the following information675−9301 30 Cedar Street Telephone: (705) for the previous account. If there is information about more than one account, please use Sudbury ON to Page 3 Fax: (705) 675−9367 page 3. go Legal Name City
P3E 1A4 Toll Free: 1−800−461−3350

Address Telephone Number WSIB Account Number

Ontario Government Complex Highway 101 East Province P.O. Bag 4020 South Porcupine ON P0N 1H0

Telephone: (705) 235−6130 Fax: (705) 235−6140 Postal Code Toll Free: 1−800−461−9856

Section C: Employer Name(s) &Road West 100 Stone Identification Telephone: (519) 826−4650

Please complete this section in full. A copy of the documents filed with the Ministry of Consumer and Business Services or any other supporting 2nd Floor Fax: (519) 826−4678 documents must be attached Guelph ON N1G 5L3 to this form. Toll Free: 1−888−259−4228 Legal Name Place an "X" in the box that describes the ownership of your operation. Trade Name(s)
153 Great Northern Road Telephone: (705) 942−3002 Sault Ste. Marie ON Fax: (705) 942−7582 P6B 4Y9 Sole Proprietorship Toll Free: 1−800−461−6005 Partnership



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CCRA No. (Revenue Canada) Bank Name


Section D: Address(es)
Work Location Please provide the physical location where the employer is carrying on business activities (i.e. not a box number or general delivery). If there is more than one work location, please use page 3. go to Page 3 Address Postal Code Payroll Address Only fill out this section if the physical location of your payroll records differs from your work location address. Address Postal Code Area Code Telephone Number Area Code FAX Number Email Address (if different) Area Code Telephone Number Area Code FAX Number Email Address (if different)

0775A (12/09) 0775A (06/09)
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on.g. go to Page 3 Address City Province Postal Code Account Number Section H: Certification I hereby certify that I am the employer (or authorized officer) responsible for paying all WSIB premiums on this account (and any linked accounts) for which the individual or entity identified under "Legal Name" in Section C is legally liable. 01JAN1995) Middle Name Title Last Name Home Address (This address must be a physical address and not a box number or a general delivery).ca go to Page 3 . go to Page 3 Personal information on this form is collected under the authority of the Workplace Safety and Insurance Act. please use page 3. managing partner. sign and return to the Workplace Safety and Insurance Board. the information on this form and on any documents attached is true and correct. If there is more than one business activity. Letters/Forms Issued WSIB Representative For WSIB Use Only 0775A2 Signature www. please call 1-800-387-8638.Section E: Business Activity Describe your business activity. does the employer have any business dealings with the associated employer(s)? yes no If you have answered "yes" to both these questions. including equipment or machinery used and materials contained in your product. 1997. If the employer has more partner(s) or executive officer(s) than the one individual shown above. If there is more than one employer. or chief executive officer. Section G: Associated Employer(s) Does the employer have an associated relationship with one or more other employers? yes no If yes. Dates Business Activity Description (e. Name (please print) Signature Title Area Code Telephone Number Date Completed (e. do you maintain segregated payrolls for each business activity? go to Page 3 yes no Please provide the trade names and business activities of three competitors. To the best of my knowledge. please Legal Name provide the name and address of the associated employer. If you have any questions. First Name Date of Birth (e. City Province Postal Code Area Code Telephone No. please use page 3.wsib.g. in the area below. and may be used to register/determine your status for coverage and to administer and enforce the Act. 01JAN1996) d d m m m y y y y Please print this document. 01JAN1996) (Include all workers' and contractors' labour) Date Help First Employed (ddmmmyyyy) Estimated Insurable Earnings for the Current Calendar Year For WSIB Use Only Start > Date Help First Employed (ddmmmyyyy) Date Help First Employed (ddmmmyyyy) If there are more than three business activities. please use page 3. Name Business Activity Section F: Owner/Executive Details Please provide the following details about the owner.g. .Employer Registration Page 3 All information is strictly confidential.wsib. Legal Name go to HOME page Start > 0775A3 go to HOME page print reset www.